
• ■ 


. - - 






LIBRARY OF .CONGRESS, 

©§iqu- ©up^rig^i Ifxu 



Shelf....T.Z.n 



UNITED STATES OF AMERICA. 



i 

A MANUAL 



OF 



OBSTETEIOS 



BY 

EDWARD L. PARTRIDGE, M.D. 



Professor of Obstetrics, New York Post-Graduate Medical 

School ; Instructor in Obstetrics, College of Physicians 

and Surgeons, New York ; Visiting Physician to the 

Maternity Hospital, and to the Nursery and Child's 

Hospital ; Attending Gynecologist to the New 

York Hospital, Out-patient Department ; 

FellojF of the New York Obstetrical 

i Q {^ Society. 



WITH SIXTY ILLUSTRATIONS 



P 7 

NEW YORK / & GGLV 

WILLIAM WOOD & COMPANY 

1884 



MS3I 

. p-7-7 



Copyright by 
WILLIAM WOOD & COMPANY. 

1884. 



PKEFACE. 



The aim of this book is to give a concise 
and correct outline of that obstetric knowledge 
especially called for on the part of the medi- 
cal student and general practitioner. 

The medical student who desires to simpli- 
fy and arrange his information, and at lei- 
sure moments to recall to his mind primary 
data necessary to his 'chain of knowledge, 
will find in this volume that which he de- 
sires, with, it is hoped, an appropriate em- 
phasis accorded to the facts and opinions 
given. A considerable experience in class 
teaching has permitted the writer to know 
what subjects are stumbling blocks to the 
student, and special effort has been made to 
treat of these so that the mind may intelli- 
gently receive, retain, and impart a knowl- 
edge of them. 

The writer having also a large personal ex- 



IV PREFACE. 

perience in obstetrics, both in hospital and 
private practice, believes himself aware of 
the needs of the practitioner as well, and in 
him he hopes to find a satisfied reader on ac- 
count of definite and proper estimate of va- 
lue which has been given to symptoms, thus 
helping him to make or confirm diagnosis, 
and to remedies and methods of treatment. 

In the effort to be concise it is believed 
that there has been no sacrifice of clearness. 



CONTENTS. 



PAGE 

Chapter I , 1-17 

Organs of Generation, Parts compos- 
ing the Vulva, Vagina, Uterus, Fallo- 
pian Tubes, Ovaries, Broad Liga- 
ments, Parovarium, Vessels, Nerves, 
and Lymphatics. 

Chapter II 18-39 

Ovulation and Menstruation, Con- 
ception and Development of the 
Ovum, Graafian follicle, Ovule, Cor- 
pus luteum, Local and constitutional 
conditions associated with Menstru- 
ation, Fecundation, Composition of 
Semen, Sites of Impregnation, 
Changes in the Ovum, Blastodermic 
Membranes, Chorion, Amnion, De- 
ciduae, Placenta, Funis, Fetal Circu- 
lation. 



VI CONTENTS. 

PAGE 

Chapter III .40-57 

Symptoms and signs of Pregnancy, 
Duration of Pregnancy, Diseases of 
Pregnancy. — Systemic changes, Ces- 
sation of Menses, Morning Sick- 
ness, Mammary Signs, Pigmenta- 
tion, Other reflex disturbances, 
Kiestine, Color of Vagina, Changes 
in the Uterus and Cervix, Quick- 
ening, Intermittent uterine con- 
tractions, Ballottement, Fetal heart- 
sounds, Uterine bruit, Duration 
of Pregnancy, Diseases of Preg- 
nancy, digestive, respiratory, ner- 
vous, and circulatory, Albuminuria, 
Vesical Irritability, Affections of par- 
turient Tract, Haemorrhoids. 

Chapter IV 58-68 

Abortion and Premature Labor. — Dis- 
eases of the Ovum, Extra-Uterine 
Pregnancy, Causes, Frequency, 
Symptoms, Prognosis, Diagnosis and 
Treatment. Moles: Carneous, Fatty, 
and Vesicular or Hydatidiform. 

Chapter V 69-106 

Anatomy of the Pelvis. — Labor. — 
The Puerperal State. 



CONTENTS. VU 

PAGE 

Os innominatum, Sacrum, Coccyx, 
Ligaments, Pelvis as a whole. In- 
clined planes, Measurements, Di- 
ameters, and Axes. The Fetal 
Head, Regions, Fontanelles, Sutures, 
Measurements. Labor: Cause of, 
Stages, "Bag of waters," Uterine 
Action, Duration, Presentation and 
Position. Mechanism in different 
head positions: Flexion, Descent, 
Kotation, Extension, and Restitu- 
tion. Moulding, caput succedaneum. 
Management of Labor: Preparatory 
and succeeding stages, Care of Peri- 
neum, Attention to the newly born 
Child, Birth of Placenta. The Puer- 
peral State: After-pains, Bladder, 
Lochia, Bowels, Retrograde uterine 
changes, Diet, Care of the Breasts. 

Chapter VI 107-125 

Precipitate, Tedious, and Obstructed 
Labor. — Deformity of Pelvis. Pre- 
cipitate and Tedious Labor: Causes, 
Symptoms, Prognosis, Treatment. 
Obstructions in Maternal Soft Parts: 
Rigid Cervix, Carcinoma, Ante par- 
turn hour-glass contraction of uterus, 



VI CONTENTS. 

PAGE 

Chapter III .40-57 

Symptoms and signs of Pregnancy, 
Duration of Pregnancy, Diseases of 
Pregnancy. — Systemic changes, Ces- 
sation of Menses, Morning Sick- 
ness, Mammary Signs, Pigmenta- 
tion, Other reflex disturbances, 
Kiestine, Color of Vagina, Changes 
in the Uterus and Cervix, Quick- 
ening, Intermittent uterine con- 
tractions, Ballottement, Fetal heart- 
sounds, Uterine bruit, Duration 
of Pregnancy, Diseases of Preg- 
nancy, digestive, respiratory, ner- 
vous, and circulatory, Albuminuria, 
Vesical Irritability, Affections of par- 
turient Tract, Haemorrhoids. 

Chapter IV .58-68 

Abortion and Premature Labor. — Dis- 
eases of the Ovum, Extra-Uterine 
Pregnancy, Causes, Frequency, 
Symptoms, Prognosis, Diagnosis and 
Treatment. Moles: Carneous, Fatty, 
and Vesicular or Hydatidiform. 

Chapter V 69-106 

Anatomy of the Pelvis. — Labor. — 
The Puerperal State. 



CONTENTS. Vll 

PAGE 

Os innominatum, Sacrum, Coccyx, 
Ligaments, Pelvis as a whole. In- 
clined planes, Measurements, Di- 
ameters, and Axes. The Fetal 
Head, Regions, Fontanelles, Sutures, 
Measurements. Labor: Cause of, 
Stages, "Bag of waters," Uterine 
Action, Duration, Presentation and 
Position. Mechanism in different 
head positions: Flexion, Descent, 
Kotation, Extension, and Restitu- 
tion. Moulding, caput succedaneum. 
Management of Labor: Preparatory 
and succeeding stages, Care of Peri- 
neum, Attention to the newly born 
Child, Birth of Placenta. The Puer- 
peral State: After-pains, Bladder, 
Lochia, Bowels, Retrograde uterine 
changes, Diet, Care of the Breasts. 

Chapter VI 107-125 

Precipitate, Tedious, and Obstructed 
Labor. — Deformity of Pelvis. Pre- 
cipitate and Tedious Labor: Causes, 
Symptoms, Prognosis, Treatment. 
Obstructious in Maternal Soft Parts: 
Rigid Cervix, Carcinoma, Ante par- 
turn hour-glass contraction of uterus, 



Vlll CONTENTS. 

PAGE 

Tumors Cicatricial closure, Cysto- 
cele, Vesical calculus, Rigid Peri- 
neum, (Edema of Vulva, Hematocele. 
Deformed Pelvis: Varieties. Rachitis, 
Osteo-malacia. Dangers to mother 
and child from labor with pelvic de- 
formity. Diagnosis. Pelvimetry. 
Treatment. 

Chapter VII 126-159 

Malpresentations. — Multiple Preg- 
nancy. — Other conditions pertaining 
to the Uterine Contents. 
Breech, Face, and Shoulder Presen- 
tations; Frequency, Varieties, Cau- 
ses, Diagnosis, Mechanism, Prognosis, 
Treatment. Management of diffi- 
cult Occipito-Posterior cases. Twins: 
Diagnosis, Peculiarity of Labor, 
Manner of presentation, Head 
locking, Prognosis, Treatment. 
Superfetation and Superfecundation. 
Excessive Fetal Development. 
Premature ossification of craniums. 
Hydrocephalus. Hydrothorax. Fe- 
tal Tumors. Monsters. Multiple 
Presentation. Dorsal displacement 



CONTENTS. IX 

PAGE 

of arm. Tough Membranes. Dry 
Labor. Long or Short Funis. 

Chapter VIII 160-179 

Haemorrhage. Accidental Haemor- 
rhage, Placenta Previa, Post-partum 
Haemorrhage, Secondary Haemor- 
rhage. Varieties, Causes, Signs and 
Symptoms, Diagnosis, Prognosis, 
Treatment. 

Chapter IX 180-205 

Unnatural and Complicated Labor. — 
Puerperal Diseases. Prolapse of the 
Funis. Inversion of the Uterus. 
Rupture of the Uterus. Lacerations 
of Cervix, Vagina, and Perineum. 
Rupture of Pelvic Joints. Puerperal 
Eclampsia. Thrombosis and Em- 
bolism. Puerperal Insanity. Fre- 
quency, Causes, Signs and Symp- 
toms, Diagnosis, Prognosis, Treat- 
ment. 

Chapter X 207-225 

Puerperal Fever, Its relation to Sep- 
ticaemia: Etiology, Nature, and Mode 
of Action of the Septic Poison. En- 
docolpitis, Endometritis, Metritis, 



X CONTENTS. 

page: 
Parametritis, Perimetritis, Perito- 
nitis, Septicaemia, Pathology, Symp- 
toms, Prognosis, Prevention, and 
Treatment. 

Chapter XI 226-277 

Obstetric Operations: The Forceps. — 
Craniotomy. — Embryotomy. — Deca 
pitation. — Cephalotripsy. — Version 
— Induction of Abortion and of 
Premature Labor . — Laparo-ely tr ot- 
omy. — Caesarean Section. — The Porro 
Operation, — The Porro-Muller Opera- 
tion. 



MANUAL OF OBSTETRICS 



CHAPTER I. 

THE ORGANS OF GENERATION. 

The Organs of Reproduction in the female 
are external or copulative, and internal or 
formative. 

The external organs, also called the vulva, 
or pudendum, consist of all the parts visible 
externally, and to these may be added the 
vagina. 

The mons Veneris is a cushion of adipose 
tissue covering the pubes. It is covered with 
skin, and after puberty is thickly supplied 
with hair. 

The labia majora are two folds of integu- 
1 



2 MANUAL OF OBSTETRICS. 

ment, of rounded form owing to adipose tis- 
sue beneath them, situated one on each side 
of the orifice of the vulva, or rima pudendi. 
They extend from the mons Veneris, uniting 
posteriorly in front of the anus. They are 
covered with hair toward the outer side, while 
the opposing internal surfaces resemble mu- 
cous membrane, being supplied abundantly, 
however, with sebaceous glands, but no mu- 
cous follicles. The underlying adipose struc- 
ture is rich in elastic tissue and blood-vessels, 
and in it the round ligament of each side ter- 
minates. After child-bearing or the wasting 
of age, the labia minora sometimes become 
visible, protruding between the labia majora. 
The extremities of the vulval fissure are 
called respectively the anterior and posterior 
commissures. The thin, crescentic fold of in- 
tegument found in front of the posterior com- 
missure is called the fourchette. 

The clitoris, analogous to the male penis, is 
a small erectile body situated half an inch pos- 
terior to the anterior commissure. It is com- 
posed of two corpora cavernosa, which are 
continuous above with two crura, the latter 
being attached to the ascending rami of the 
ischia and the descending rami of the pubes. 
The glans is its rounded free extremity. It 






MANUAL OF OBSTETRICS. 



has a miniature prepuce and f renum and is 

supplied with highly developed, terminal 

nerve bulbs, and abundant venous capillaries. 

The labia minora or nymphce are two nar- 




Fig. 1.— External Organs of Generation. 
1, Labia majora; 2, Fourchette; 3, Labia minora; 4, 
Clitoris; 5, Meatus urinarius; 6, Vestibule; 10, Mons 
Veneris; 11, Anus. 

row folds of mucous membrane arising from 
the prepuce and frenum of the clitoris above, 



4 MANUAL OF OBSTETRICS. 

and terminating opposite the middle of the 
labia majora. Pavement epithelium covers 
their surfaces, which present small papillae, 
and sebaceous glands having an odorous, 
cheesy secretion. 

The vestibule is a triangular space bounded 
by the nymphae as they diverge from the cli- 
toris, and having the meatus urinarius, as a 
small prominence with central opening, at the 
middle of its lower boundary. The urethra, 
one and one-half inches long, extends back- 
ward, underlying the anterior wall of the 
vagina. It is extremely dilatable, though, by 
virtue of its muscular and elastic structure, 
readily recovering its natural size. 

The internal pudic artery conveys blood to 
the vulva, the return circulation being 
through an extensive plexus of veins which 
chiefly constitute what is called erectile tis- 
sue. 

The bulbi vestibuli, each an inch in length 
when distended, are two leech-shaped con- 
glomerations of these veins, lying on each 
side of the opening of the vagina, between it 
and the sides of the pubic arch. They are 
connected with the veins of the clitoris, there 
being a smaller, intermediate plexus on each 
side called the pars intermedia. During co- 



MANUAL OF OBSTETRICS. 5 

ition these veins, which have no valves, are 
turgid. 

The vulvo-vaginal glands, first described by 
Bartholin, lie behind and more deeply seated 
than the bulbi vestibuli, being opposite the 




Fig. 2. 

A, pubis; B, B, ischinm; C, clitoris; D, glans of the 
clitoris; E, bulb ; F, constrictor muscle of the vulva; 
G, left pillar of the clitoris ; H, dorsal vein of the cli- 
toris; I, pars intermedia; J, vein communicating with 
obturator vein ; K, obturator vein ; M, labia minora. 

posterior boundary of the vaginal orifice. 
Each is as large as an almond, conglomerate, 
discharging by a single duct a copious, 
slightly viscid secretion at the posterior edge 



6 MANUAL OF OBSTETRICS. 

of the vaginal orifice during coition and labor. 
The fossa navicularis is a shallow depression 
lying between the fourchette and perineum, 
the latter structure being muscular and tri- 
angular, having a base of an inch and a half 
extending under the skin from the vagina to 
the anus. Its apex is upon a higher level be- 
tween the same tube structures. It serves as 
a column of support for the internal organs 
of generation, and the importance of care for 
its preservation during labor is obvious. 

The Vagina is the curved canal connecting 
the external parts with the uterus. Through 
it the semen ascends, and the menstrual flow 
and products of gestation descend. Naturally 
it is collapsed, being more capacious above, 
and occupies the axis of the pelvis except 
that the lower end lies much nearer to the 
pubes than to the coccyx. 

The anterior wall is two and one-half, the 
posterior three inches in length. Posteriorly, 
the middle three-fifths are contiguous to the 
rectum, except for a thin layer of connective 
tissue; between the upper fifth and the rectum, 
the pouch of peritoneum, called the cul-de-sac 
of Douglas, intervenes, while the lower fifth 
is situated in front of the perineal body. The 
anterior wall is connected with the bladder 



MANUAL OF OBSTETRICS. 7 

and urethra by connective tissue. The upper 
end of the vagina, extending higher behind 
than in front of the cervix, is called the fornix. 
The wall is composed of involuntary muscular 
fibres, both longitudinal and circular, which 
are closely interwoven, surrounded by a sheath 
of connective tissue. The lining of mucous 
membrane possesses numerous vascular pa- 
pillae, but no secreting glands, and is covered 
with pavement epithelium. It presents nume- 
rous transverse folds, called imgce, which 
are removed by parturition. The anterior 
and posterior vaginal columns, situated in the 
median line, are longitudinal ridges, the an- 
terior being the more prominent. A network 
of capillary vessels encompasses the vagina. 
The sphincter-vagince muscle surrounds the 
lower extremity, and the vaginal orifice is 
more or less closed by a thin, crescentic fold 
of mucous membrane, called the hymen, the 
remains of which, after child-bearing, consist 
of fleshy eminences, called caruneuloz myrti- 
formes, about five in number. 

The Internal Organs are the uterus, Fal- 
lopian tubes, and ovaries. 

The uterus is a hollow, flask-shaped organ, 
situated between the bladder and rectum, its 
summit being below, and its long diameter 



8 



MANUAL OF OBSTETRICS. 



corresponding to the axis of, the pelvic brim, 
It is capable of frequent and considerable 
change of position, owing to its suspension by 
connective tissue and ligamentous structures, 
and to changing conditions of the adjacent 




Fig. 3. — Uterus, Vagina, etc. 

organs. It has an upper convex border, the 
posterior surface being convex, the anterior 
flattened. Its superior angles are the points 
of entrance of the Fallopian tubes, its width 



MANUAL OP OBSTETRICS. 



9 



at this region being an inch and a half. The 
walls vary in thickness at different points, be- 
tween three and four lines near the cervix, 
and ten or twelve at the centre of the body. 
Its cavity measures two and one-half inches, 




Fig. 4.— Uterine Cavity. 

its weight is a little more than an ounce, and 
it is divided into three parts : the fundus, that 
portion above the entrance of the Fallopian 
tubes ; the cervix, which is the lower portion 
shaped like an inverted truncated cone ; and 
the body, which intervenes between the fun- 



10 MANUAL OF OBSTETRICS. 

dus and cervix. The slight constriction at 
the junction of the cervix and body makes 
the uterus pear-shaped, and it is opposite this 
point that the peritoneum is reflected from 
the uterus upon the bladder, while posteriorly 
the peritoneal covering descends so as to cover 
the upper part of the vagina before being re- 
flected upward upon the rectum. Laterally, 
the peritoneum spreads outward to the sides 
of the pelvis, forming the broad ligaments. 




Fig. 5.— Utricular glands of the Uterus. 

The cavity of the body is lined with mucous 
membrane which is continuous with that of 
the Fallopian tubes and of the cervix. It is 
closely attached to the subjacent uterine 
structure, is one-twelfth of an inch thick, and 
presents columnar epithelium covered with 
cilia. The shape of the cavity is triangular, 
and the walls are separated by a small collec- 
tion of mucus only. The utricular glands are 
tubular, having single or branching, blind 



MANUAL OF OBSTETRICS. 11 

extremities, being lined by cylindrical cells. 
Their depth corresponds to the thickness of 
the mucous membrane. Beneath and be- 
tween them are capillaries which are the 
source of the menstrual flow. The cavity of the 
cervix is fusiform ; its narrowed points of 
communication with the uterine cavity and 
with the vagina are called respectively the 
internal and external os uteri. The arbor 
vital consists of four firm 'prominent ridges — 
anterior, posterior, and lateral — with trans- 
verse ridges arising at angles more or less 
acute. On the summits of, and in the sulci 
between these ridges, are the openings of 
simple follicles, called glands of Naboth, 
which secrete the alkaline, transparent, viscid 
mucus which always occupies the cervical 
cavity. Toward the external os, are seen 
numerous clavate papillae which are simply 
elevations of mucous membrane. The upper 
part of the cervix is lined with columnar and 
ciliated epithelium, while that found in the 
lower portion and on the external surface of 
the cervix is tesselated. The uterine wall is 
composed of unstriped muscular fibres, con- 
nective and elastic tissue, the former greatly 
predominating. The developed muscular 
fibres are fusiform, containing a nucleus, 



12 MANUAL OF OBSTETRICS. 

while small undeveloped corpuscules are 
numerous. During pregnancy only, the ar- 
rangement of these fibres can be seen com- 
prising three layers. The thin, superficial 
layer arises at the cervix, and passes upward 
and outward toward the Fallopian tubes. 
The middle, thick layer is a close interlace- 
ment of fibres surrounding the blood-vessels. 
The thin, internal layer consists of circular 
rings having for their centres the orifices of 
the Fallopian tubes and the os uteri. 

After child-bearing, the uterus is larger, 
more rounded, with a somewhat patulous 
cervix and external os, the latter more or less 
fissured. 

Folds of peritoneum maintaining the ute- 
rus in position are called vesico-uterine, 
sacro-uterine, and broad ligaments. 

The Broad Ligaments, consisting of two 
layers of peritoneum passing from the ante- 
rior and posterior surfaces of the uterus to 
the sides of the pelvis, divide the cavity of 
the latter into two parts, and each ligament 
contains, in its folds, loose cellular tissue, 
some muscular fibres continuous with those 
of the uterus, the round ligament, ovary, 
parovarium, Fallopian tube, blood-vessels, 
nerves, and lymphatics. 



MANUAL OF OBSTETRICS. 13 

The round ligaments, mainly of muscular 
structure, pass from the upper angles of the 
uterus downward and forward through the 
inguinal rings into the labia majora. 

The Fallopian Tubes, three or four inches 
in length, pass from the uterus outward, 
downward, and backward. Each terminates 
in a free extremity near the ovary. It trans- 
mits the spermatozoon toward the ovary, and 




Fig. 6.— Ovary and Fallopian tube, the latter laid 
open. 

the ovum to the uterus. It can be felt, cord- 
like, at the upper edge of the broad ligament. 
The walls — consisting of external or longi- 
tudinal and internal or circular, unstriped 
muscular fibres — have an internal lining of 
mucous membrane covered with ciliated epi- 
thelium, producing a current toward the 
uterus. The lining membrane presents nu- 



14 MANUAL OF OBSTETRICS. 

merous longitudinal folds. The outer fimbri- 
ated extremity is expanded and trumpet- 
shaped, having fringe-like processes, one of 
which, being longer than the others, is 
attached to the ovary, and directs the ex- 
ternal orifice downward to receive the dis- 
charged ova. The mucous lining is continu- 
ous with the peritoneal covering. The 
uterine opening of the tube is slightly dilated, 
and will admit a fine bristle. Galvanism 
shows the tubes to possess peristaltic move- 
ment which assists the movements of sperma- 
tozoa and ova. 

The Ovaries are flattened ovoid bodies, an 
inch and a half long, three-fourths of an 
inch in breadth, and half an inch thick, 
each weighing about eighty grains. Situ- 
ated nearer to the pelvis than to the uterus, 
each is united to the latter by a band called 
the ligamentum ovarii. The posterior layer 
of the broad ligament covers the ovary, and 
that portion which surrounds the vessels 
which enter the ovary on its anterior surface 
is called the mesentery of the ovary. The 
point at which the vessels enter is called 
the hilum. The layer of the broad ligament 
which cover the free surface of the ovary 
differs from peritoneum in that it is covered 



MANUAL OF OBSTETRICS. 15 

by cylindrical (in early life called germ epithe- 
lium) instead of tesselated epithelium. This 
explains the statement, which is frequently 
seen, that the peritoneum does not cover 
the ovary. Beneath this layer is the tunica 
albuginea, a strong, fibrous covering, closely 
connected with the ovarian body. The ovary 
is composed of two parts, the medullary por- 
tion, which is reddish, spongy, and vascular, 




Fig. 7. 
and the cortical portion, of grayish color, 
containing the Graafian follicles. The ovary 
is made up of muscular structure, connec- 
tive tissue, and elastic fibres, the cortical 
portion containing less muscular and more 
connective structure than the medullary por- 
tion. 

The Parovarium or organ of Bosenmuller 



16 MANUAL OF OBSTETRICS. 

is found between the layers of the broad liga- 
ment, near, and connected with, the upper 
and outer part of the ovary. It is the ana- 
logue of the epididymis in the male, and is 
the remains of the Wolffian body. It con- 
sists of slightly tortuous, closed tubes, ten to 
twenty in number, arranged in pyramidal 
shape with the apex toward the ovary. 

The vascular supply to the internal organs 
of generation is derived from the internal 
iliac and ovarian arteries. The vessels enter 
and return between the layers of the broad 
ligaments. The arteries of the uterus are 
unusually large for an organ of its size, and 
on account of their tortuous course are called 
curling arteries. 

The vessels of the ovary enter and leave at 
the hilum. The cellular tissue structure of 
the broad ligaments contains an elaborate 
network of veins, two portions of which are 
called respectively the plexus uterinus and 
the plexus pampiniformis. 

Nerves of the uterus are from the sympa- 
thetic system, with some filaments, chiefly 
about the cervix, from the cerebro-spinal 
system. 

Lymphatic vessels are found throughout 
the uterus and adjacent cellular tissue ac- 



MANUAL OF OBSTETRICS. 17 

companying the veins, and beneath the 
mucous membrane of the uterus and between 
its muscular fibres are found numerous 
lymph spaces. 



CHAPTER II. 

OVULATION AND MENSTRUATION— CONCEPTION, 
AND DEVELOPMENT OF THE OVUM. 

The Graafian Follicles are formed dur- 
ing fetal life from the germ epithelium cov- 




Fig. 8. 

ering the ovary, inflections of that covering 
taking place, bringing them into the ovarian 
structure. Of an entire number of about 



MANUAL OF OBSTETRICS. 



19 



thirty thousand, comparatively few become 
mature. "When undeveloped they can be seen 
by the aid of high magnifying power only, but 
having reached maturity they are visible to 
the naked eye as prominent vesicles on the 
surface of the ovary. With the general de- 
velopment attending puberty the first follicle 
matures, and during, the child-bearing age a 
similar change occurs in one or more of the 




Fig. 9.— Graafian Follicle. 
1, Ovule; 2, Membrana granulosa; 3, Tunica propria; 
4, Tunica fibrosa ; 5, Ovarian stroma. 

follicles at regular periods, except during 
pregnancy and lactation. As the Graafian 
follicle becomes ripe it approaches the sur- 
face of the ovary, and consists of an invest- 
ing membrane composed of two layers ; the 
external, highly vascular, called the tunica 
fibrosa, and the internal, or tunica propria. 



20 MANUAL OF OBSTETRICS. 

Within is found the membrana granulosa, 
which consists of cylindrical epithelial cells, 
while at one point in the cavity of the folli- 
cle, near the surface, the ovule is seen situ- 
ated in a dense aggregation of the cells of 
the membrana granulosa, known as the 
discus proligerus. The remainder of the 
cavity of the follicle is occupied by a trans- 
parent fluid called the liquor folliculi, which 
is traversed by a few filamentous bands 




Fig. 10.— Human Ovule. 
2, Zona pellucida; 3, Germinal vesicle; 4, Macula ger- 
minativa. 

or retinacula. The fluid of the follicle is 
formed by disintegration of cells of the 
granular membrane. The ovule is a cell T £o 
of an inch in diameter, having a thick wall 
called the zona pellucida, or vitelline mem- 
brane. Its cavity contains a granular mass 
of protoplasm called the vitellus or yelk. Near 



MANUAL OF OBSTETRICS. 21 

its centre is the germinal vesicle, a clear cell 
t4q of an inch in diameter, and contained 
within this is the germinal spot, ^-^ of an 
inch in diameter. Ovulation consists in the 
maturation of the Graafian follicles and dis- 
charge of the ova. The liquor folliculi, in- 
creasing in amount, stretches and thins the 
wall of the follicle until its rupture takes 
place, this latter event being precipitated by 
sudden tension produced by ovarian conges- 
tion, usually with hemorrhage into the folli- 
cle, which may result from menstrual or 
sexual excitement. This laceration allows 
the escape of the ovule surrounded by cells of 
the membrana granulosa. The cavity of the 
follicle after escape of the ovule is soon lined 
and then filled with convolutions of a yellow 
color. When examined, these are found to 
consist of granular material, resulting from 
absorption of coloring matter from the blood 
previously effused in the follicle, and from 
proliferation of the cylindrical epithelium 
which remains from the membrana granulosa. 
Numerous capillaries appear in the walls of 
the follicle. 

The corpus luteum is the name given to the 
follicle thus altered, which, under the stimu- 
lus of pregnancy, increases in size until the 



22 MANUAL OF OBSTETRICS. 

fourth month, and then slowly diminishes 
until complete atrophy has taken place, six or 
eight weeks after labor. The greatest size at- 
tained is an inch in length by half or three 
quarters of an inch in thickness. If impreg- 
nation does not occur, the development is 
never greater than to equal the size of a small 
pea, and at the end of two months a stellate 
cicatrix alone remains. 

Menstruation is the sanguineous discharge 
from the uterus regularly recurring about 
every twenty-eight days, from the time of 
puberty until the menopause. It is often ir- 
regular during the early months and those 
preceding its final discontinuance, and usu- 
ally does not occur during lactation or wast- 
ing diseases. Normally about three ounces of 
blood are lost, which is kept from coagulating 
in the cervix by the alkaline secretions of the 
glands of Naboth, and, unless an excessive 
hemorrhage takes place, the admixture of 
vaginal mucus is sufficient to prevent coagu- 
lation in the vagina. 

The greater part of the uterine mucous 
membrane is shed at each menstrual period, 
being renewed subsequently. In most women 
menstruation is coincident with maturation 
or rupture, of the Graafian follicle, the con- 



MANUAL OF OBSTETRICS. 23 

gestion of the ovary producing, through its 
nervous connection with the uterus, a similar 
condition of that organ. 

Conception, which is the first stage of 
generation, results from the physiological 
union of the elements of life from both 
sexes. 

The semen contains the vivifying princi- 
ple of the male. It is a secretion from the 
testicle after puberty, opalescent, slightly 
viscid, has a faint, peculiar odor, and con- 
tains inorganic salts, chiefly phosphates and 
chlorides, and an albuminous ingredient 
called spermatine. Microscopically, it is 
found to consist of transparent fluid derived 
mainly from the prostate and Cowper's 
glands, but partly from the testes, sperma- 
tozoa and sperm cells, the latter being seen 
only in the recent secretion within the tes- 
ticles. 

The spermatozoon, which is essential to 
fecundation, has an entire length of 60 o of 
an inch, and consists of an oval head ^gn of 
an inch in diameter, and a filamentous ex- 
tremity. The sperm cells are spherical, con- 
taining three to ten nuclei. Each nucleus, 
called later in its development, secondary cell 
or vesicle of evolution, produces a sperma- 



24 



MANUAL OF OBSTETRICS. 



tozoon. The wall of the secondary cell 
usually disappears before rupture of the 
sperm (or parent) cell, leaving a cluster of 
spermatozoa within the latter cell. Finally, 
on rupture of the germ cell, the spermato- 
zoa are disseminated throughout the semen. 
The sites OF impregnation are usually the 
surface of the ovary or the outer part of the 




Fig. 11. 

Fallopian tube, and fecundation results from 
a penetration of one or more of the sperma- 
tozoa into the ovule. This may occasionally 
take place in the cavity of the uterus, while 
in the lower animals the spermatozoa have 
been seen in the ovule while still contained 
in the unruptured Graafian follicle. The 
spermatozoa may retain vitality for eight or 
ten days after entering the female organs, or 
may be detroyed by acid vaginal secretions 



MANUAL OF OBSTETRICS. 25 

before reaching the uterus. They may be 
thrown directly into the uterus, or, if depos- 
ited at the vulva, may ascend, owing to their 
power of motion derived from the vibratile, 
cilia-like extremity. 

After entering the uterus, ascent is favored 
by capillary attraction, which force depends 
upon the nearness of the internal uterine 
surfaces. Peristaltic action of the Fallopian 
tubes aids the passage toward the ovary. 

The ovule, if it escapes the vivifying con- 
tact of the spermatozoon, disintegrates in a 
short time after its discharge from the ovary. 
Whether or not fecundation occurs, there is 
a disappearance of the germinative vesicle 
and the appearance of a small bluish spot at 
some point underlying the zona pellucida, 
indicating the situation at which the cepha- 
lic end of the fetus would be formed. This 
is called the polar globule. The yelk also 
contracts, and at one point leaves a space 
called the respiratory chamber, which is usu- 
ally filled with a transparent fluid. 

Changes in the Ovum appear within 
twenty-four hours after fecundation, the 
first being the appearance of the vitelline 
nucleus, which is a small, clear vesicle like 
an oil drop, in the centre of the vitellus. 



26 



MANUAL OF OBSTETRICS. 



Segmentation of the yelk immediately fol- 
lows, consisting in a cleavage into two parts, 
each part into two others; and a similar con- 




Fig. 12. — Segmentation of the Ovum. 

tinuation of this division produces a mass of 
small spheroidal bodies each containing a 
cell, formed from the vitelline nucleus, which 
divides and subdivides with the division of 



MANUAL OF OBSTETRICS. 21 

the yelk. The mass thus formed is called 
the muriform body. These cells uniting by 
their edges, become flattened, and retiring 
toward the circumference of the yelk, leave 
a central space containing clear fluid. This 
peripheral wall of cells then separates into 
three layers, known as blastodermic mem- 
branes. The external, or epiblast, being that 
part from which the bones, muscles, integu- 
ment, nervous system, serous membranes, 
and amnion are developed. The internal, or 
hypoblast, forms the alimentary canal, while 
the middle layer, or mesoblast, forms the 
circulatory system and the bladder. The 
area germinativa next appears, and is an ag- 
gregation of the cells of the blastoderm, oval 
in shape, having in its centre the faint indi- 
cation of the foetus called the primitive trace. 
Immediately surrounding the latter is a 
translucent area called the area pellucida. 
On each side of the primitive trace, ridges, 
called lamince dorsales, appear, which meet, 
producing a canal between them which con- 
tains the spinal cord. The embryo becomes 
arched, the convexity looking outward, the 
cephalic and caudal ends approaching each 
other. The amnion, one of the foetal enve- 
lopes, is formed from the epiblast, arising by 



28 



MANUAL OF OBSTETRICS. 



two projections, one from each foetal end. 
These taking a curved direction, pass over 
the back of the foetus until they meet. It is 
continuous with the integument of the foe- 
tus, and covers the umbilical cord. The 
projections of the amnion which approach 
S 3, 




Fig. 13.— Area Germinativa. 
1. Zona pellucida; 2. Germinal membrane; 3. Area 
vasculosa; 4. Area pellucida; 5. Primitive trace. 

each other in front of the fetus, constrict the 
hypoblast, a portion of which becomes in- 
cluded within the fetus and forms the ali- 
mentary canal, while, connected with this by 
the vitelline duct, the much larger portion 
remains suspended from the abdomen of the 



fetus. 



forming 



the umbilical vesicle. The 



MANUAL OF OBSTETRICS. 29 

vitelline duct and a vascular arrangement 
known as the omphalo -mesenteric circulation, 
convey pabulum to the fetus from the um- 
bilical vesicle, until the supply is exhausted, 
and then the shriveled remains of the vesicle 
only are found attached by a filamentous 
pedicle to the fetus. This may be seen as 
large as a flattened pea, after delivery at 
term, between the chorion and amnion, usu- 
ally near the placenta. 




Figs. 14 and 15.— Early Development of the Ovum. 

The allantois, developed from portions of 
the internal and middle blastodermic layers, 
appears about the twentieth day as a sac-like 
projection from the inferior end of the ab- 
dominal opening, passing forward through the 
space (which contains, also, the pedicle of the 
umbilical vesicle) still left between the amni- 
otic projections in front of the fetus. The 



30 



MANUAL OF OBSTETRICS. 



allantois completes its course in a few days 
by expanding rapidly until it completely 
lines the external blastodermic layer, and in 




Figs. 16 and 17.— Formation of Amnion and Umbilical 

Cord. 
the structure of the allantois a vascular sys- 
tem is developed which unites the fetus to 
the mother and by which it begins to be 



MANUAL OF OBSTETRICS. 31 

nourished, coincident with the failure of sup- 
ply from the umbilical vesicle. The projec- 
tions of the amnion having met behind the 
fetus, a closed cavity is formed which contains 
a watery fluid, the liquor amnii, secreted by 
the epithelial lining of the amnion. This 
fluid, gradually accumulating, distends the 
amnion until it is pushed in contact with the 
chorion, the space (while it existed) between 
the amnion and chorion having been occupied 
by the vitriform body, composed of a gelatin- 
ous material, analogous to Wharton's jelly, 
traversed by filamentous cords. The liquor 
amnii surrounds the fetus, and increasing in 
amount, allows its movements to be compara- 
tively painless to the mother and, at the same 
time, protects it from injury. 

The Chorion : The external investing 
membrane of the ovum, at first called the 
primitive chorion, consists of the vitelline 
membrane with an outer albuminous coating, 
serving for nutrition, derived from the Fallo- 
pian tube during the passage of the egg. 

The true chorion, formed later, consists of 
the external blastodermic layer reinforced by 
the allantois. These, rising up until in con- 
tact with, finally take the place of, the primi- 
tive chorion. On its external surface a shaggy 



32 MANUAL OF OBSTETRICS. 

appearance is soon observed, owing to the de- 
velopment of thickly-set, branching, finger- 
like processes called villi. They force them- 
selves into the substance of the decidua, soon 
rendering the decidua and chorion inseparable. 
At first non-vascular, after the growth of the 
allantois each villus receives an arterial twig, 
which gives off a branch to each process of 
the villus. The villi are equally distributed 
over the entire chorion until the end of the 




Fig. 18.— DeciduaB. 
second month, when they gradually disappear, 
except over one portion, where, by their still 
greater development, the placenta is formed. 
The decidu^e are the coverings of the ovum 
afforded by the uterus, and consist of hyper- 
trophied mucous membrane with special in- 
crease of the inter-glandular connective tissue. 
Under the microscope are seen connective 
tissue cells and fibres, and utricular gland 
tubes. The increased blood-supply to the 



MANUAL OF OBSTETRICS. 33 

pregnant uterus leads to the formation of 
these membranes. The ovum having entered 
the uterine cavity, becomes lodged in some 
crypt of the lining membrane, and is soon 
surrounded by the developing deciduae. The 
decidua vera is the lining proper of the uterus, 




Fig. 19. -Placenta and umbilical cord. 
and that portion of it situated between the 
ovum and the uterus is called decidua serotina. 
After, lodgment of the ovum, processes of 
membrane grow up about its circumference, 
finally inclosing it, and this is called decidua 
reflexa. The end of the third month is nearly 
reached before the egg has attained a size 
sufficient to occupy the entire uterine cavity. 
When, however, this is accomplished, the re- 



34 



MANUAL OF OBSTETRICS. 



flexa and vera are brought in contact. After 
the third month these membranes gradually 
become thin and fibrous, and near the end of 
pregnancy their attachment to the uterus be- 
comes loosened by fatty degeneration. 
The Placenta conveys nutriment to, and 




Fig. 20.— A villus. 

oxygenizes the blood of, the fetus, and from 
the time of its formation to its full growth 
varies only in size. At term it is eight inches 
in diameter, of circular shape, spongy consist- 
ency, weighing from sixteen to twenty-four 



MANUAL OP OBSTETRICS. 35 

ounces. The cord is inserted near the centre 
usually, — sometimes near the edge producing 
resemblance to a battledore, —the amnion 
being reflected from its fetal surface so as to 
form a sheath for the cord. 

It consists of an enlargement, lengthening 
and branching of the villi of the chorion over 
a certain area usually situated near the fun- 




Fig. 21.— Villi of chorion dipping into uterine sinus. 

dus uteri. Minutely examined, the maternal 
surface shows the villi described, which dip 
into the large uterine blood-channels called 
sinuses. Each villus has a thin wall through 
which, by endosmosis, there pass nutrient, 
proximate principles and oxygen from the 
mother's blood into the blood of the fetus 
which circulates through the villi. There is 
no direct interchange of blood between fetus 



36 



MANUAL OF OBSTETRICS. 



and mother. The decidua which lay beneath 
the placenta, becoming part of its structure, 
it is in this that the large sinuses are found 
containing maternal blood. 

The Umbilical Cord, or funis, averaging 
twenty inches in length, of about the size of 
the little finger, connects the fetus with the 




Fig. 22.— Section of placenta. 
1, Umbilical cord; 2, 3, serous covering; 4, 5, 6. pla- 
cental vessels from fetus; 7, 8, uterine sinus carrying 
maternal blood. 

placenta, and carries blood to and from the 
latter. It is composed of the pedicle of the 
allantois with the umbilical vein and two 
arteries, the remains of the pedicle of the um- 
bilical vesicle, the gelatin of Wharton, and 



MANUAL OP OBSTETRICS. 37 

an outside sheath of amnion. The arteries 
take a spiral direction, as often toward the 
right as toward the left, terminating in the 
capillary branches to the villi. The gelatin 
of Wharton constitutes most of the bulk of 
the funis, protecting its vessels from injury . 
It contains amorphous matter and some con- 
nective-tissue cells, derived chiefly from the 
allantois. The cord has been seen as short as 
three, and as long as sixty inches. 

The Fetal Circulation has certain inter- 
esting peculiarities depending chiefly upon 
the absence of the pulmonary function in the 
fetus. The blood from the placenta entering 
at the navel goes to the liver, a small part 
serving to nourish that organ while the greater 
part enters the inferior vena cava through the 
ductus venosus. Here it becomes mixed with 
blood from the fetal lower extremities. 

Entering the right auricle, this blood passes 
directly through the foramen ovale, guided 
by the Eustachian valve, to the left auricle, 
and through the left ventricle and aorta to 
the head and upper extremities. 

Returning, it enters the right auricle again, 
and this current of blood passes in front of 
the Eustachian valve into the right ventricle. 
Entering the pulmonary artery, a small 



38 



MANUAL OF OBSTETRICS. 



amount supplies the quiescent lungs, while 
the greater part passes directly through the 
ductus arteriosus, reaching the aorta beyond 




Fig. 23. 
a, Ductus venosus; d, umbilical vein; g, vena portae; 
h, hepathic vein; r, ductus arteriosus. 

the giving off of the innominate, carotid, and 
sub-cl avian arteries, and continuing down- 
ward, supplies the lower part of the fetus. 
The blood is then returned through the um- 



MANUAL OF OBSTETRICS. 39 

bilical veins to the placenta, though some 
passes into the inferior cava and upward, to 
be again circulated through the fetus. 

After birth, when aeration of the blood de- 
pends on the respiratory function, the ductus 
arteriosus, ductus venosus, and umbilical ves- 
sels are converted into fibrous cords, and the 
Eustachian valve permanently closes the 
foramen ovale. 

It can be readily perceived, therefore, that 
the large size of the fetal liver and brain, dis- 
proportionate to other organs, is the result of 
a supply of purer blood to them than to other 
fetal parts. 



t 



CHAPTER III. 

SYMPTOMS AND SIGNS OF PREGNANCY. — DURA- 
TION OF PREGNANCY.— DISEASES OF 
PREGNANCY. 

Pregnancy exerts certain general effects 
upon the system. 

The entire volume of blood is increased, 
mainly by increase of the watery elements. 
There is a larger amount of fibrin (hyperinosis) 
and an increased number of leucocytes, with a 
deficiency of red corpuscles, albumen and salts. 
Urea and carbonic acid are present in con- 
siderable quantity. The increased amount of 
blood, with hydrsemia, and the vascular area 
increasing with uterine growth, call for in- 
creased cardiac action which brings about 
slight cardiac enlargement. The augmented 
activity in other organs tends to slight in- 
crease in their size also. 

A decided impression upon the nervous 
system is perceived. Pregnant women are 



MANUAL OF OBSTETRICS. 41 

whimsical and generally depressed, tjhough 
exhilaration of spirits is sometimes seen. 

Osteophytes, or thin calcareous deposits^ 
are often found on the inner surface of the 
calvarium. 

Cessation of menses is the rule in pregnancy, 
and gives the first warning of the condition. 
Sanguineous discharge, when occurring after 
impregnation, is usually from some part of the 
cervix, is caused by erosion or polypus, and is 
irregular in time and amount. There are a 
few instances in which a menstrual discharge 
continues regularly, throughout a portion or 
the whole of pregnancy, from some part of 
the uterine surface not in contact with the 
ovum, or from the cervix, and in these cases it 
is probable that the function of ovulation 
is not in abeyance. Amennorrhoza without 
pregnancy may result from well-known 
causes. A knowledge of the patient's men- 
strual habits, absence of other signs of 
pregnancy, with frequently some characteris- 
tic disturbance of the general health, will aid 
in the diagnosis. In healthy women, habit- 
ually regular, cessation of menses indicates 
pregnancy in 80 per cent of instances. Preg- 
nancy may occur in girls who have never 
menstruated. 



42 MANUAL OF OBSTETRICS. 

Nausea and vomiting, called also morning 
sickness, most commonly begins in the second, 
rarely lasting after the fourth month. These 
signs may commence earlier, or continue to 
the end of pregnancy. In typical cases, the 
woman has nausea upon the first movement 
from the recumbent posture in the morning, 
and vomits occasionally during the forenoon, 
either food which has been taken, or glairy 
mucus. The disturbance is produced in a 
reflex way from irritation of uterine nerves, 
and cases of unusual severity are often expli- 
cable by the discovery of unusual uterine ten- 
sion, displacements, flexions, or morbid con- 
ditions of the cervix. These symptoms may 
be intentionally simulated, or nervous women 
who desire or fear pregnancy may imagine 
them present in the lesser degree. 

Cravings for unusual articles of food are 
very common in pregnancy. 

Mammary changes, dependent upon the in- 
timate relation through the nervous system, 
between mammae and uterus, begin about the 
second month. At first tender and slightly 
enlarged, the breasts become more firm, with 
marked appearance of superficial veins. The 
follicles in the areola surrounding the nipple, 
some of which communicate with the lacti- 



MANUAL OF OBSTETRICS. 



43 



ferous tubes, become enlarged and quite 
prominent. The nipple becomes erect and 
turgid, being covered with scales formed from 
epidermis and the drying of watery milk 
which begins to be secreted after the fourth 
month. The breasts continue to enlarge, and 
the areolce darken from pigmentation, in- 




Fig. 24. 

crease in area, and become prominent. The 
secondary areola consists of less pigmented 
spots irregularly situated just beyond the 
periphery of the areola. These changes in 
color are most marked in persons of dark 
complexion. The mammary signs are not 



44 MANUAL OF OBbTETRICS. 

fully developed, until others, quite as indica- 
catory of pregnancy, are present, and as they 
somewhat remain after child-bearing, they 
are most important in primiparae. Even the 
presence of milk in the breasts of primiparae 
is not conclusive, as it has been observed in 
young girls, and even in the male breast. 

Pigmentation is common along the median 
line of the abdomen, and often present about 
the face. 

Other reflex disturbances, such as syncope, 
ptyalism, and toothache, are common enough 
to be regarded as the result of something more 
than accidental coincidence. 

Kiestine is a peculiar, albuminoid pellicle 
containing triple phosphate crystals and 
vibriones, always present in the urine of preg- 
nant women between the second and eighth 
months. It is present under other conditions 
than pregnancy, and can be of only corrobora- 
tive importance. It appears in from two to 
five days after urine is voided, rises to the 
surface, and finally disintegrates. 

Changes in the uterus can be noted between 
the second and fourth months under the favor- 
ing conditions of lax abdominal walls, with 
little adipose tissue. The uterus becomes en- 
larged and globular , often imparting a sense 



MANUAL OP OBSTETRICS. 45 

of fluctuation to the examining finger. The 
increase in growth of its walls is from develop- 
ment of the muscular fibres and cells. It early 
acquires slight right obliquity, which it 
usually retains. Before the fourth month, it 
often descends a little in the pelvis, producing 
flattening of the region between the pubes and 
navel. After the fourth month, the fundus 
is perceptible above the pubes; at the sixth 
month, a little above the umbilicus ; and at the 
middle of the ninth, just below the ensiform 
cartilage. During the last two weeks of preg- 
nancy, the uterus descends somewhat. Dur- 
ing the latter half of pregnancy, it projects 
anteriorly, so that its axis forms with the 
horizon an angle between 30° and 45°. The 
navel usually protrudes. 

The cervix, early in pregnancy, becomes 
softened and enlarged, being occupied by a 
mucous plug. It makes much less resistance 
to the examining finger, there being also a 
fulness of the lower uterine segment and 
vagina, therefore, as pregnancy advances, the 
impression of a shortened cervix is conveyed. 
No shortening actually occurs, except during 
the few weeks preceding labor, when some 
unfolding takes place from below upward — 



46 MANUAL OF OBSTETRICS. 

the internal os almost always remaining un- 
disturbed. 

Vesical symptoms, such as frequent desire 
to urinate, with or without pain, occur chiefly 
during the second and third months, and 
again late in pregnancy, from descent and 
pressure of the uterus against the bladder. 

The vagina acquires a deep blue color from 
impediment to return of venous blood from 
uterine pressure — other results of the constant 
congestion being moderate hypertrophy of its 
walls and leucorrheal discharge. All the pel- 
vic connective tissue becomes succulent. 

Quickening is the perception of fetal move- 
ments by the mother. This usually occurs at 
about four and one-half months, as it is not 
until then that the movements attain much 
vigor, or that the uterus is in contact with 
the anterior abdominal wall, by which the 
impulse of movements is more readily appre- 
ciated than by the uterine surroundings in 
the pelvis. The earliest sensation is of slight 
fluttering, but in advanced pregnancy the 
movements are violent and often painful. 
"Women who are either not pregnant or carry 
dead children so often claim to perceive quick- 
ening, mistaking for it the motion of flatus, 
or the rolling of a dead child, that the symp- 



MANUAL OF OBSTETRICS. 47 

torn is not uniformly reliable. Women are 
occasionally delivered of living children, who 
have not been conscious of quickening during 
the latter part, or even the whole of preg- 
nancy. 

Intermittent uterine contractions, not pro- 
ductive of pain, occur during the whole of 
pregnancy. At any time when the hand can 
be placed upon the uterus, if retained there 
sufficiently long, a marked hardening can be 
perceived occurring at intervals of about ten 
minutes. B allot tem3iit, or passive motion of 
the fetus is a siga obtainable between four 
and one-half and seven months. When un- 
questionably recognized by an experienced 
observer, it is a certain indication of preg- 
nancy. For examination the patient should 
be placed upright or semi-recumbent, and the 
examining finger placed against the lower 
segment of the uterus in front of the cervix 
A sharp push is made with the finger, and 
the fetus, being in contact with the inner wall, 
is made to rise in the liquor amnii, and, fall- 
ing, strikes against the finger, informing the 
operator of its presence. External ballotte- 
ment is the same manoeuvre practised on the 
outside of the abdomen with the woman on 
her side. 



48 MANUAL OP OBSTETRICS. 

The fetal heart sounds afford an infallible 
sign, being heard with increasing force and 
distinctness after the fifth month. The fre- 
quency is between 120 and 160. As a rule, 
the larger the child the slower is the pulse — 
and as large children are more frequently males 
than females, the rapidity of the fetal heart is a 
guide to the sex of the child in a majority of 
cases. The site at which the sounds can be 
heard varies with the position of the fetus. 
The most common situation is midway be- 
tween the navel and left, anterior, iliac spine, 
the back of the child serving best for their 
transmission. When the child is alive, they 
may not always be heard, owing to some po- 
sition which fails to allow of transmission to 
the examining ear. Repeated auscultation 
rarely fails to find them, however. 

Fetal movements and discovery of fetal 
parts, as recognized by the physician, consti- 
tute an infallible proof of the condition, but 
may not be obtained owing to death of the 
fetus, or to adipose deposit in the abdominal 
wall. Jerky action of abdominal muscles may 
simulate fetal movements. 

The uterine bruit is a whizzing murmur 
produced after the fourth month by the 
blood passing through the sinuses and enlarged 



MANUAL OF OBSTETRICS. 49 

curling arteries of the uterus. It was erro- 
neously attributed to the utero-placental cir- 
culation until it was shown to be present for 
several days after delivery, or when the uterus 
contained fibroids, or in cases of placenta pre- 
via, heard only at the fundus. 

Differential diagnosis between pregnancy 
and ovarian or fibroid tumors, ascites, adipose 
cake, menstrual retention, subinvolution, 
areolar hyperplasia, or phantom tumor re- 
quires thoughtful attention, but to properly 
discuss this subject would involve a consider- 
ation of the histories of these conditions 
which would be out of place in this volume. 

The Duration of Pregnancy is about 278 
days, the time being divided by various 
writers into periods of forty weeks, ten lunar 
months, or nin3 calendar months. The exact 
day of conception — not the fertile coition — 
can never positively be known, owing to the 
fact that spermatozoa may retain their vitality 
in the female organs for some days before 
their contact with an escaping ovule. It is 
generally true that conception occurs at some 
time during ten days immediately succeeding 
a menstrual epoch, and the simplest way to 
estimate the probable date of labor is to add 
seven days to the date of the beginning of the 



50 MANUAL OP OBSTETRICS. 

menstrual period and count back three 
months. Thus, if a woman began to menstru- 
ate on September 20th, an estimate made in 
this way would fix upon June 27th as the 
day nearest to her delivery. Occasionally 
impregnation occurs within a day or two pre- 
ceding the time at which menstruation is ex- 
pected, and the discharge does not occur. In 
such instances — generally recognizable only 
after labor — nearly ten months elapse between 
menstruation and labor. 

The Diseases op Pregnancy arise by 
sympathetic irritation, by mechanical pres- 
sure, or in the uterus itself, and many of 
them are simply exaggerated symptoms. 
They may be classified into those involving, 
Indigestion; 2d, respiration; 3d, the ner- 
vous system ; 4th, circulation ; 5th, secretion 
and excretion ; 6th, the uterus. 

Digestion. — a. Nausea and vomiting may 
be present to a degree which involves the 
comfort or threatens the life of the patient. 
When excessive and long continued, great 
prostration ensues, in part from the distress 
of the condition itself, in part from its result 
— inanition. It must be remembered that a 
pregnant woman can bear considerable dis- 
comfort from nausea and vomiting without 



MANUAL OF OBSTETRICS. 51 

serious effect upon her general condition, yet 
when they persist during all parts of the 
twenty-four hours for a considerable time, 
grave symptoms appear, such as emaciation, 
rapid and weak pulse, coated and dry tongue, 
pinched countenance, and, in the worst class 
of cases, insomnia, pain, fever, great thirst, 
fetid breath, and hcematemesis. Finally, and 
often fortunately, unless relief is obtained, 
the uterus expels its contents. 

TJie treatment is to promote nutrition, 
while medicinal agents are used to control 
the cause of the symptoms. To promote nu- 
trition, regulate the functions of the entire 
alimentary tract, and use highly nutritious 
diet in small amounts, frequently given, and 
when the patient is recumbent. Nutritive 
enemata often prove of great help. Applica- 
tions to epigastrium of blistering agents or 
ice are useful. Internally, bismuth, oxalate 
of cerium, acid hydrocyan. dil., creasote, ef- 
fervescing drinks, champagne, koumyss, 
minim doses of vinum ipecac, and chloral by 
the rectum are suitable. Restore and main- 
tain the normal position of the uterus when 
necessary, and treat the cervix according to 
any indications which may be present. In 
grave cases which resist all other treatment, 



52 MANUAL OF OBSTETRICS. 

induce abortion, but never without profes- 
sional consultation. 

b. Acid dyspepsia, or heart-burn, is com- 
mon during the latter part of pregnancy. 
Palliation only can be hoped for by the use 
of carbonate of magnesia, or some other 
alkaline salt. It ceases after delivery. 

c. Constipation, from local pressure and 
defective rectal innervation, is very common. 
Beside the usual discomfort which attends a 
loaded rectum, there is liability to abortion 
from straining at stool, and to the production 
of false pains toward the end of pregnancy. 

Treatment, if scybalous masses are present, 
should be by enemata. Mineral waters or a 
dinner pill are useful* 

d. Diarrhoea in pregnancy should receive 
prompt attention, as ib may cause abortion. 
Loose passages from the upper part of the 
large intestine escaping through a channel in 
the middle of a loaded rectum constitute a 
not uncommon disorder, which calls for lax- 
atives, enemata, or both. 

Respiration. — Dyspnoea and laryngeal 
cough, of reflex nature, occurring at any time 
in pregnancy call for such remedies as bella- 
donna, acid hydrocyan., morphia, or chloral. 
In the latter months, the enlarged uterus 



MANUAL OF OBSTETRICS. 53 

may greatly embarrass respiration by me- 
chanical pressure. For this avoid any addi- 
tional pressure by tight clothing. 

Nervous System. — a. Neuralgia is com- 
mon, either of reflex character or from anae- 
mia. Anodynes, tonics, and local sedative 
applications are useful. 

b. Insomnia in the latter months may 
greatly deteriorate strength and cause much 
suffering. Prompt relief usually attends the 
employment of the bromides, codeia, or 
chloral. 

c. Pruritus vulvae, resulting from leucor- 
rhoeal discharge, or more commonly from 
irritation of cutaneous nerves by local con- 
gestion, is both intolerable and intractable. 
Some relief can be obtained from liniments 
containing camphor and chloroform. If of 
leucorrhoeal origin, employ mildly astringent 
injections with small vaginal tampon to ab- 
sorb discharge. 

d. Chorea may be evoked by pregnancy 
when the patient has had previous similar 
trouble. General hygiene and sedatives, 
such as the bromides, are indicated. The 
condition may be so serious in its conse- 
quences upon the general health or mental 
state as to call for the induction of labor. 



54 MANUAL OF OBSTETRICS. 

e. Paralyses are generally of transitory 
nature, produced by anaemia, hysteria, or 
uraemia. If possible, the cause should be re- 
moved. With labor, recovery usually takes 
place. 

Circulation.— The condition of the blood, 
previously described as present in pregnancy, 
favors palpitation, syncope, and oedema. 
There may be a nervous element in the pro- 
duction of the two first conditions, while 
mechanical pressure may aid in causing the 
latter in some locations. Iron, bitter tonics, 
and rectal injections of blood are useful. 

Haemorrhoids and varicose veins of labia 
and lower extremities are common. Partia 
relief only can be obtained before labor. The 
usual treatment should be resorted to, with 
measures to obviate pressure from the en- 
larged uterus. Operative procedures to re- 
lieve haemorrhoids should be postponed, if 
possible, yet are safer in result than prolonged 
irritation and suffering. 

Secretion and Excretion.— a, Ptyalism 
is rare, and is best treated by astringent 
washes, tannin lozenges, and counter-irrita- 
tion over salivary glands. 

b. Retention of urine occurs in some in- 
stances when, late in pregnancy, the child is 



MANUAL OF OBSTETRICS. 55 

low in the pelvis. Urination may be pos- 
sible in the recumbent or knee-chest position. 
A broad, abdominal bandage, lifting the 
uterus, should be worn. 

c. Incontinence of urine is distressing and 
irremediable. Local, oleaginous applications 
will somewhat obviate resulting cutaneous 
irritation. 

d. Albuminuria, or the presence of albu- 
men in the urine, is more common in preg- 
nancy than formerly supposed. While al- 
ways affording reason for watchful care, it is 
only when present in considerable or increas- 
ing amount, with indications of imperfect 
elimination of urea, that serious apprehension 
should be felt. Albuminuria is more com- 
mon in the latter months, and in the great 
majority of cases results from renal conges- 
tion produced by interference with return of 
blood through the renal veins from pressure 
of the uterus upon them. It may be caused 
also by pressure on the ureters, by the altered 
blood state, by reflex irritation, by exposure 
to cold, or by previously existing renal dis- 
ease. The earlier symptoms are oedema of 
face and extremities, nausea with or with- 
out vomiting, occasional headaches, and 
diminished secretion of urine. Later, we 



56 MANUAL OF OBSTETRICS. 

may have severe and frequent headaches, 
dim and blurred vision, presence of blood 
and casts in the urine, and urcemic convul- 
sions and coma. Premature labor some- 
times occurs. Albuminuria is more com- 
mon in primiparce and twin cases. 

The treatment of albuminuria, indicating, 
as it does, more or less imperfect elimination of 
urea, should be directed to the relief of renal 
congestion. Diuretics such as tinct. ferri ehlo- 
rid. and acetate of potassa; laxatives, prefera- 
bly the salines, and diaphoretics should be em- 
ployed. A natural condition of the skin 
should be promoted by bathing and inunction. 
Dry cups and counter-irritation over the kid- 
neys are serviceable. A simple diet, with 
an abundance of milk and an avoidance of an 
excess of nitrogenous food, nourishes, acts 
healthily on the kidneys, and keeps the forma- 
tion of urea to the minimum. 

When the subjective symptoms of partial 
uraemic poisoning are prominent and persis- 
tent, induction of labor may be performed 
after proper consultation. 

Uterus. Retroversion should be reduced 
by placing the patient in Sims', or the knee- 
chest position, a suitable pessary being 
used to keep the fundus from fixation below 



MANUAL OF OBSTETRICS. 57 

the sacral promontory. Cervical erosions, if 
present to a considerable degree, require 
cleansing and astringent applications. Treat- 
ment by the prolonged use of the vaginal 
douche or tampon is objectionable. 



CHAPTER IV. 

ABORTION AND PREMATURE LABOR.— DISEASES 
OF THE OVUM. — EXTRA-UTERINE PREGNANCY. 

Abortion is the expulsion of the products 
of gestation before the viable period, i. e., the 
7th month. 

Premature labor occurs between this time 
and term. Some writers choose to speak of 
expulsion of uterine contents before the 4th 
month as abortion; between the 4th and 7th 
months, as miscarriage, and between the 7th 
month and term as premature labor. 

Abortion is believed to occur once to every 
eight or ten term deliveries. 

The causes of abortion and premature 
labor are classified as, a, external, b, 
maternal, c, fetal. A, External are falls, 
blows, and the use of the sound, douche, etc., 
as in criminal cases. B, Maternal, are fa- 
tigue, emotional excitement, febrile affections, 



MANUAL OP OBSTETRICS. 59 

albuminuria, syphilis, oxytocics, uterine dis- 
orders such as lacerated cervix, adhesions, 
uterine irritability owing to previons abor- 
tions, cellulitis, peritonitis, and reflex irrita- 
tions as from suckling or inflamed hemor- 
rhoids. C, Fetal, are syphilis when con- 
tracted through the father, extravasations of 
blood beneath or between the membranes, 
and degenerations of fetus or secundines. 

The immediate cause, consequent upon 
some of the conditions mentioned, is partial 
or general uterine congestion. Symptoms 
are, first, those produced by uterine hyper- 
emia, such as vesical and rectal irritation, 
and aching in back and loins, with bearing- 
down sensations. Hemorrhagic discharge 
and recurrent pain from uterine contractions 
follow. Before the stage is reached when 
regular pains and hemorrhage coexist, abor- 
tion may be averted. Before the formation 
of the placenta — i. e. , 3d month — the ovum is 
usually expelled entire with unruptured 
membranes. Between the 4th and 7th 
months there is commonly escape of the fetus 
followed by placenta and ruptured mem- 
branes. After the 7th month the manner of 
expulsion resembles that attending term 
labor. The progress of abortion is ascertained 



60 MANUAL OF OBSTETRICS. 

upon local examination. The earlier uterine 
contractions dilate the cervix sufficiently to 
allow the later contractions to expel the con- 
tents of the uterus. 

Prognosis generally favorable. The results 
may be death from hemorrhage, septicaemia, 
or local inflammations. These dangers are 
much greater in criminal than in spontaneous 
abortion. Chronic uterine disease is a frequent 
sequence, due more to thoughtless or ignorant 
mismanagement than to abortion itself. 

Treatment may be prophylactic by doing 
away with causes such as we fear may pro- 
duce abortion, with especial caution to avoid 
fatigue and excitement. 

When symptoms of abortion are present, its 
prevention may be accomplished by absolute 
rest, preferably dorsal decubitus with eleva- 
tion of pelvis by raising the foot of the bed. 
This should be continued for some days after 
symptoms subside. Opium in moderate, re- 
peated doses is of great service; viburnum 
prunifolium has been recommended by some 
writers. Internal use of hemostatics and ex- 
ternal applications are useless, the latter 
being often promotive of abortion. 

If the cervix dilates, pain and hemorrhage 
continuing, abortion is inevitable. To assist 



MANUAL OF OBSTETRICS. 61 

uterine action, give ergot. To facilitate cer- 
vical dilatation and control hemorrhage, use 
the vaginal tampon, exchanging it for a fresh 
one every six or eight hours in order to prevent 
accumulation and decomposition of discharge, 
and to ascertain the progress of the case. 
Examine all the vaginal discharges, for, by 
learning their nature, a knowledge of the 
progress of the case is aided. When cervical 
dilatation is obtained, if the ovum be not ex- 
pelled, introduce and sweep about the finger 
to dislodge the uterine contents. In pro- 
tracted cases of abortion, never leave to na- 
ture the removal of retained portions of the 
ovum. If necessary, dilate the cervix with 
sea-tangle tents and remove the uterine con- 
tents with the finger rather than with instru- 
ments. In cases which have sustained much 
manipulative treatment, freely employ anti- 
septic injections. After abortion, confine the 
patient to bed for a week. 

Moles are retained, degenerated ova with 
death of the fetus, the latter event being 
sometimes the cause, at other times the re- 
sult. 

The carneous mole appears as a firm, 
fleshy ovoid consisting chiefly of a thick wall 
produced by hemorrhages into or beneath the 



62 MANUAL OF OBSTETRICS. 

decidua. The blood solidifies, becomes fibril- 
lated and retains its color, thereby suggesting 
the name, carneous. In the centre of the 
mass a small cavity is found containing fluid 
with rarely any trace of fetus. The degenera- 
tion commonly begins before the 3d month, 
the mass being discharged between the 3d 
and 6th months. When retained for a num- 
ber of weeks, a low form of growth and de- 
velopment occurs. 

The fatty mole is nothing more than a car- 
neous mole which has undergone fatty change. 
It resembles the latter in all respects except 
that its color has altered from red to yellowish. 

The vesicular or hydatidiform mole con- 
sists of a collection of vesicles attached 
to each other and to membranous stalks. 
The vesicles contain transparent liquid, 
and vary in size between a small shot 
and a grape. Essentially a disease of the 
chorion, each vesicle is an altered villus. The 
villi degenerate by proliferation and subse- 
quent liquefaction of their epithelial and con- 
nective-tissue cells. If the degeneration is 
general, as it usually is, the fetus dies, disin- 
tegrates, and disappears. The formation of 
the vesicular mole never begins later than the 
end of the 3d month. The positive sign of 



MANUAL OF OBSTETRICS. 63 

the condition is sight of some of the cysts in 
the vaginal discharge. Suspicions may have 
been aroused by uterine growth dispropor- 
tionate to the period of pregnancy, and a 
doughy sensation conveyed to the finger in 
the vagina. Occasionally the disease prima- 
rily affects so small part of the chorion that 
the fetus continues to develop for a time. 
Ultimately the mass is expelled. 

False moles are collections of blood, mu- 
cous membrane, secretions, etc , unconnected 
with pregnancy, sometimes found in the 
uterus. 

Treatment is to secure removal of the en- 
tire mass. Hemorrhage, which may be se- 
vere, must be guarded against, as in the 
treatment of abortion. 

Other affections of the ovum are hydram- 
nion, or great excess of liquor amnii, placental 
inflammations, degenerations and anomalies 
in form, knots in the funis, and fetal degene- 
rations and diseases. 

EXTRA-UTERINE PREGNANCY. 

Extra-uterine pregnancy is the develop- 
ment of the ovum in some situation outside 
of the uterine cavity. Varieties are: ovarian, 
tubal, and abdominal. Ovarian pregnancy 



64 MANUAL OP OBSTETRICS. 

may arise, first, by penetration of spermato- 
zoa into the unruptured Graafian follicle fol- 
lowed by fecundation and lack of discharge of 
the ovum (the possibility of this is denied by 
some, though confirmed by our knowledge of 
the lower animals); second, spermatozoa may 
enter through a rent in the follicle, with 
failure of discharge of the ovum. Pregnancy 
may occur in the Fallopian tube so near, the 
ovary that, as development proceeds, the 
original relation of component parts is so lost 
that it would appear as if — and the pregnancy 
practically is — ovarian. This variety is prop- 
erly called tubo-ovarian. Tubal pregnancy 
may occur in any part of the tube. "When 
occurring at the extremity in the uterine 
wall, it is called interstitial. The varieties 
of abdominal pregnancy are: a s primary, 
when the ovum falls into some part of the 
peritoneal cavity and there develops; and, 
b, secondary, when rupture of tubal pregnancy 
occurs and further development takes place in 
the abdominal cavity. 

Causes of extra-uterine pregnancy are ob- 
structions to the passage of the ovum to the 
uterus, as flexions of the Fallopian tube, 
extra or intra-tubal adhesions, mucous or 
polypoid growths. It more frequently oc- 



MANUAL OF OBSTETRICS. 65 

curs after than before the age of thirty, and 
often after some years of sterility. The 
corpus luteum is sometimes found in the 
ovary opposite to the tube in which develop- 
ment occurs. 

The fetal membranes develop in the usual 
way in extra-uterine pregnancy, the villi 
of the chorion- penetrating into subjacent 
tissues. The uterus undergoes slight sym- 
pathetic development, with hypertrophic 
changes in its mucous lining. 

Symptoms of tubal pregnancy are those of 
ordinary pregnancy, except that an irregular 
uterine discharge of blood is common from 
the beginning, and often hypogastric pains. 
At some time, between the fourth and twelfth 
weeks, the thinned tube structures rupture. 
All the symptoms of shock, hemorrhage, and 
commencing peritonitis follow. Frequently 
the patient dies. Before rupture occurs, a 
local examination would show the presence 
of a growing mass at one side of the uterus. 
If the patient survives the rupture, the 
products of gestation may continue to develop, 
being surrounded and shut off from the rest 
of the peritoneal cavity — as in primary ab- 
dominal pregnancy — by a gradually thicken- 
ing, low form of connective tissue. More 



6G MANUAL OF OBSTETRICS. 

frequently, the fetus dies and undergoes some 
form of degeneration. 

Both primary and secondary abdominal 
gestation may advance to term. Then pseudo- 
labor occurs, the uterus expels its decidual 
lining, and the child soon dies. The de- 
vitalized products of gestation may remain 
encysted and quiescent for years, being trans- 
formed into adipooere or a calcified mass, or 
may excite suppuration in adjacent tissues 
until, after formation of fistulous tracts, they 
escape in fragments through either the ab- 
dominal wall, bladder, vagina, or bowel. 
Months and years may elapse before this slow 
process of disintegration and elimination is 
completed, and during this time the patient 
may suffer, and at the end perhaps die, from 
blood-poisoning, or from the exhaustion of 
prolonged suppuration. Women carrying an 
extra-uterine fetus have been known to pass 
through succeeding natural pregnancy. 

Treatment. — The diagnosis of early tubal 
pregnancy having so commonly an element 
of doubfc, operative procedures have rarely 
been instituted. When positive diagnosis 
has been agreed upon, abdominal or vaginal 
section and removal of the tumor, with ovary 
and tube of the affected side, as in ovario- 



MANUAL OF OBSTETRICS. 67 

tomy, would be proper. When rupture oc- 
curs, the symptoms of collapse and hemor- 
rhage must be met. Possibly, the hitherto 
untried operation of laparotomy, removal of 
blood, fetus, etc., with ligature of bleeding 
vessels, might prove successful. 

To destroy the fetus, prevent growth and 
render the tumor inert, a continuous current 

m 

of electricity may be passed through it by 
means of fine needles introduced into the sac. 
Galvanic shocks, injection of poisonous 
agents into the sac, and withdrawal of liquor 
amnii are methods which have been sug- 
gested or employed for the same purpose. 

Abdominal pregnancy, at or near term with 
fetus living, may be treated by primary lapa- 
rotomy. The chief danger is from haemor- 
rhage, which will best be guarded against by 
leaving the placenta untouched, to be expelled 
after natural separation at a period of some 
days after operation. Cleanliness and anti- 
septic precautions will do much toward se- 
curing favorable results. Secondary opera- 
tion for removal of fetus, is performed after 
waiting to observe what channel nature 
selects for elimination. The measures, which 
look toward facilitating fetal removal, are 



i 



68 MANUAL OF OBSTETRICS. 

enlarging, or making openings into the cyst 
by caustics or incision. 

Pregnancy in one horn of a double 
uterus may occur so as to closely simulate 
extra-uterine pregnancy. Efforts at differ- 
entiation will succeed only after close study 
of the history, and local signs where there is 
suspicion of the, existence of either condi- 
tion. The majority of cases of pregnancy 
in double uterus terminate favorably without 
unusual treatment. 

Extra-uterine pregnancy must be diagnos- 
ed from hematocele, cellulitis in one broad 
ligament with or without abscess, ovarian 
and fibroid tumors. 



CHAPTER V. 

THE ANATOMY OF THE PELVIS AND FETAL 
HEAD. — NORMAL LABOR; ITS CLINICAL PHE- 
NOMENA AND MECHANISM IN VERTEX 
CASES.— MANAGEMENT OF NORMAL LABOR,— 
THE PUERPERAL STATE. 

The Pelvis, composed of the ossa innomi- 
nata, sacrum, and coccyx, protects from injury 




Fig. 25.— Pelvis. 



the organs which it supports, and gives at- 
tachment to muscles. The sacrum is 4^ inches 



70 MANUAL OF OBSTETRICS. 

long, wedge-shaped, having a breadth at the 
superior portion, or base, of 4 J inches. It 
unites the innominate bones posteriorly, and 
has upper, anterior, and posterior surfaces, 
lateral borders, and to its lower extremity is 
appended the coccyx. Composed of five ver- 
tebrae, their union is bony after puberty. Its 
posterior surface is rough for attachment of 
muscles and ligaments, and presents foramina 
for exit of the sacral nerves. The anterior 
surface is smooth and excavated, forming the 
hollow of the sacrum, its greatest depth, 
about an inch, being just below the upper 
border of the third vertebra. The anterior 
sacral nerves emerging upon this surface may 
be so pressed upon by the child's head as 
to produce severe cramp in the muscles 
of the leg. The anterior surface of the 
first sacral vertebra, at the upper part, 
projects and is called the promontory. The 
superior surface articulates with the last 
lumbar vertebra. The lateral borders, some- 
what flaring and approaching each other as 
as they descend toward the coccyx, constitute 
broad articular surfaces. 

The coccyx, attached to the lower end of 
the sacrum by a joint permitting of motion, 



MANUAL OF OBSTETRICS. 71 

is triangular, apex downward, and composed 
of four rudimentary vertebrae. 

The ossa innominata — Each bone roughly 
resembles a figure eight, and consists of three 
parts, the ilium, ischium and pubis which 
meet at the acetabulum, forming in early 
life a Y-shaped, cartilaginous joint. 

TJie ilium has a rough external surface and 
rounded superior border, the crest, to which 
muscles are attached, and at each extremity 
of this border are prominences called respec- 
tively, anterior and posterior superior spines. 
At a little lower level, separated from these 
by slight excavations, are smaller projections, 
called the anterior and posterior inferior 
spines. The greater part of the internal 
surface presents a concavity called the 
iliac fossa, occupied by muscle. The posterior 
portion looking backward and inward, artic- 
ulates with the sacrum. The fossa is bounded 
below by the linea ilio-pectinea with its emi- 
nence, which is sharply defined and forms a 
considerable portion of the brim of the true 
pelvis. 

The ischium is the lowest part of the os in- 
nominatum, having a body which forms a 
large part of the acetabulum, a large, rough 
tuberosity on which we sit, a spine which 



<2 MANUAL OF OBSTETRICS. 

projects backward and inward from the 
lower posterior part of the body, and an as- 
cending ramus which passes upward and for- 
ward from the tuberosity to the descending 
ramus of the pubis. The excavated border 
of the ischium above the spine is called the 
greater sciatic notch, the lesser excavation 




Fig. 26. 

below the spine being known as the lesser 
sciatic notch. 

The pubis is the smallest portion and joins 
with its fellow of the opposite side to complete 
the pelvic circumference anteriorly, that part 
which extends from the point of union to the 
body being called the horizontal ramus, hav- 
ing a small projection, called the spine, near 



MANUAL OF OBSTETRICS. 73 

the inner superior border. The body consti- 
tutes a part of the acetabulum, while the por- 
tion which passes from the union of the pubic 
bones downward and outward to the ischium 
is the descending ramus. This, with its fel- 
low of the opposite side forms the pubic arch. 
The obturator foramen is inclosed by the 
bodies and several rami of the ischium and 
pubis. 

The symphysis pubis is the articulation of 
the pubes, rendered strong by fibrous bands. 
The articulating surfaces are covered by car- 
tilage which are separated by a small syno- 
vial sac. 

TJce sacro-iliac synchondrosis is the name 
of the joint formed by ilium and sacrum, and 
has cartilaginous plates and synovial sac. 
The joint is given great strength by ligamen- 
tous bands crossing from bone to bone. 

During pregnancy the fibro-cartilaginous 
structures of these joints become succulent 
and during labor slight motion of them is 
permitted. 

Ligaments. The posterior sacro iliac liga- 
ments are of great importance, for by their 
attachment to the rough, external, posterior 
surfaces of the ilia and to the posterior sur- 
face of the sacrum, they maintain the sacrum 



74 MANUAL OF OBSTETRICS. 

from being depressed from its position by- 
weight of the body. Through them the 
weight of the trunk is distributed to the ilia 
and femora. 

The greater sacro-sciatic ligament arises 
from the posterior part of the ilium and the 
posterior surface and side of the sacrum and 
coccyx. Converging, the fibres cross to the 
tuber ischii. 

The lesser sacro-sciatic ligament lies ante- 
rior to the former, passing from a similar 
origin on the sacrum and coccyx to the spine 
of the ischium. These ligaments convert the 
greater and lesser sciatic notches into fora- 
mina. 

The pelvis as a whole. The linea ilio- 
pectinea separates the upper portion, or false 
pelvis from the lower, or true pelvis, the lat- 
ter only, being of special obstetric importance, 
though the flaring ilia of the former form 
shelves to support the uterus during preg- 
nancy. 

The posterior inclined plane of the pelvis 
is found on either side, being that area situ- 
ated posterior to a line drawn from the mid- 
dle of the ilio-pectineal line downward to the 
spine of the ischium, having a general slope 
downward, backward, and inward toward the 



MANUAL OF OBSTETRICS. 75 

sacrum and coccyx. The presence of the 
sacro-sciatic ligaments makes it more exten- 
sive. 

The anterior, inclined plane is that surface 
anterior to the line mentioned and has a gen- 



COCCYX 



fUSHEQ BAC& 




pianeof quil1t 
Fig. 27. 



eral direction, forward, downward, and in- 
ward toward the arch of the pubes. 

The upper and lower openings of the pelvic 
canal are termed the superior and inferior 
straits, each having a corresponding imagi- 
nary plane. 

"With the woman in an erect posture, the an- 
gle formed by the plane of the brim with the 
horizon is 60°; that of the plane of the outlet 



76 MANUAL OF OBSTETRICS. 

with the horizon, 16°; that of the plane of the 
cavity with the horizon, 40° — the promontory 
of the sacrum being four inches higher than the 
pubes. The angle formed by the pubic arch is 
90° to 100°. The depth of the anterior pelvic 
wall is 1J in.; the lateral, 3J in.; the posterior 
5k to 6 in. The plane of the superior strait 
is cordate, that of the outlet being diamond 
shaped. 

The oblique diameters are lines extending 
from the sacro-iliac synchondroses to the 
diagonally opposite ilio-pectineal eminences, 
that starting from the right synchondrosis 
being usually called the right, that from the 
left synchondrosis being spoken of as the left. 
The antero-posterior diameter is also called 
the conjugate or the sacro-pubic. 

Approximate measurements are: 

Antero-posterior. Oblique. Transverse. 
Brim 4.25 in. 4.75 in. 5.2 in. 

Cavity 4.7 ". 5.3 " 4.75 " 

Outlet 5. " 4.25" 

The space between the inner pelvic walls 
and the contained hollow viscera is occupied 
by muscular and connective tissue. This les- 
sens the above diameters about quarter of an 
inch, except the transverse of the brim which 



MANUAL OF OBSTETRICS. 77 

is shortened half an inch, or even more, by 
the presence of the psoas and iliacus muscles. 

External measurements are, between the 
anterior superior spines of the ilia, 10 inches; 
between the middle points of the iliac crests, 
10| inches; between the symphysis pubis and 
spinous process of the lower lumbar vertebra, 
7 inches. These have slight importance only. 

The axis of the superior strait is a line per- 
pendicular to its plane, if extended, it would 
touch the umbilicus and tip of the coccyx, 
and with this the axis of the uterus corre- 
sponds. A line perpendicular to the plane of 
the pelvic outlet would touch the sacral pro- 
montory. This line differs in direction from 
the axis of the outlet of the parturient canal 
which varies according to the amount of pe- 
rineal distention. 

The female pelvis differs from that of the 
male in being more spacious and less deep. 
It is more delicate, having less prominent pro- 
cesses. 

The Fetal Head is composed of three 
principal parts, i. e., the face, the base, and 
the vault. Sutures of importance are the 
sagittal, extending from before backward be- 
tween the parietal bones; the frontal, a con- 
tinuation of the sagittal which separates the 



78 MANUAL OF OBSTETRICS. 

two halves of the frontal bone; the lambdoi- 
dal which separates the occipital from the 
parietal bones: and the coronal which sepa- 
rates the frontal from the parietal bones. 

The font anelles, two in number, are mem- 
branous spaces present at the intersection of 
the sutures. The anterior, called also the 
bregma, is diamond shaped, its four sides 
being formed by the rounded corners of the 
two halves of the frontal, and the parietal 
bones. 

The posterior fontanelle, at the junction of 
the two parietal and occipital bones, is trian- 
gular and much smaller. 

The sinciput is the frontal region. 

The vertex is the highest part of the cra- 
nial vault, a region immediately posterior to 
the anterior fontanelle. 

Approximate diameters. 

Occipitofrontal . .4.50 inches. 

Occipito-mental 5.30 

Suboccipito-bregmatic 3.50 

Cervico-bregmatic 3.75 

Fronto-mental 3.25 

Bi-parietal 3.75 

Much change in the form of the head is per- 



MANUAL OF OBSTETRICS. 79 

missible by overlapping of the bones of the 
cranial vault, at the sutures. 



DCqPlTO-UEHTAL-,_ 

' ^FRCNTO-MEimvU 



OCCIPITOfRONtAL. 




Fig. 28. 

Normal Labor, Its Clinical Phenomena, 
and Mechanism in Vertex Cases. 

The immediate cause of labor is, probably, 
commencing fatty degeneration of the decid- 
uae. Other causes, accepted by some, are ex- 
treme distention of the uterus, a condition of 
the blood surcharged with carbonic acid, and 
ovarian stimulation at the end of the ninth 
month. All such causes act through the 
nervous system stimulating uterine action to 
the point of establishing labor. 

The preparatory stage occupies one or two 
weeks preceding labor, the symptoms being 
sense of fulness about back and hips, not 
constant, with irregular lancinating pains in 



80 MANUAL OF OBSTETRICS. 

hypogastrium, vesical and rectal irritability, 
and increased mucous discharge sometimes 
blood-tinged and then called a show. The 
cause of these symptoms is the settling down 
of the uterus into the pelvis, and coincident 
with them there is relief to any existing re- 
spiratory trouble. False pains produced in a 
reflex way from pressure of a distended rec- 
tum are often mistaken for the pain of the 
preparatory, and even of the first stage of 
labor. 

Labor is divided into three stages. The 
first, or stage of dilatation, terminates when 
the cervix has attained that degree of expan- 
sion which permits the passage of the fetus. 
The second, or stage of expulsion, continues 
from the end of the first stage until delivery 
of the fetus. The third is the period occupied 
in delivery of the placenta and ends when 
efficient and safe contraction of the empty 
uterus is secured. 

Dilatation of the cervix is accomplished by 
intermittent contractions of the uterine mus- 
cular fibres, and the first stage is, therefore, 
mainly governed by the sympathetic system. 
This period is much longer than the succeed- 
ing stages. At the beginning of labor, ute- 
rine contractions, which cause pain in the 



MANUAL OF OBSTETRICS. 81 

ilioinguinal region or back or in both situa- 
tions, occur every half-hour. The pains 
gradually become more severe and frequent, 
until toward the end of the first stage their 
frequency is once in five or ten minutes. 
The uterine action is general from the first, 
having somewhat more vigor in the highly- 
developed muscular tissue of the body and 
fundus. The effect of this general contrac- 
tion is to cause the uterine contents to seek 
some outlet and the presence of the cervical 
opening allows the liquor amnii, prevenU d 
from escape by unruptured membranes, to 
specially impinge upon that region as a small 
dilating wedge. The arrangement of the 
muscular tissue of this region in preponder- 
ating longitudinal fibres which also contract, 
assists dilatation. Hypercemia of the cervix 
is allowed, owing to absence of surrounding 
and supporting viscera, which are present at 
the body and fundus, and this congestion 
leads to local succulency and softening which 
greatly facilitate cervical dilatation. As ex- 
pansion advances, the hydrostatic dilating 
force of membranes and inclosed liquor am- 
nii acts to greater advantage until they form 
a most efficient, protruding wedge. As the 
cervix approaches full dilatation, some re- 



82 MANUAL OF OBSTETRICS 

traction of it takes place, which expands the 
upper part of the vagina, already rendered 
dilatable by hypersemia and abundant mu- 
cous secretion. When the cervix is nearly 
or wholly expanded, uterine action is usually 
sufficient to cause rupture of the membranes. 
S)me liquor amnii escapes, but the head 
quickly descends to occupy the dilated cervix 
causing retention of the greater part. 

The second stage begins after a slight 
pause, and by the increasing force and fre- 
quency of uterine contractions, aided by ac- 
tion of abdominal muscles, the descent of the 
fetus takes place. The cerebro-spinal ner- 
vous system now lends its aid to the sympa- 
thetic, the pains are thereby augmented, and 
they occur with increasing frequency until 
toward the close of this stage one may occur 
every two or three minutes. They become 
bearing down, and are felt over the whole 
abdomen. The head passes the lower pelvic 
strait, the perineum is made tense until the 
vulval opening looks nearly forward and 
finally the presenting part is born with, in 
primiparae, some laceration of the vulval 
commissures and borders. The body of the 
child, together with pent up liquor amnii, 



MANUAL OF OBSTETRICS. 83 

quickly follows, usually with the succeeding 
contraction of the uterus. 

Nausea and vomiting during the first, and 
slight syncope and rigors at the end of the 
second stage may take place. 

The intermittent nature of uterine action 
is important, as the intervals between pains 
afford rest to the mother, allow relief to what 
would otherwise be constant and dangerous 
pressure of the head upon maternal soft 
parts, and permit time for the restoration of 
the equilibrium of the utero-placental circu- 
lation. 

The third stage. With, or immediately 
after the birth of the child, the placenta is 
partly detached, and the uterus contracts 
upon it as an irregularly globular or flask- 
shaped body. After a period varying between 
five and thirty minutes, uterine contraction 
expels the placenta and membranes with 
some liquid and coagulated blood which has 
accumulated in or behind them. Further, 
undue loss of blood is prevented by closure 
of uterine sinuses by contraction of the ute- 
rine fibres, and formation of coagula in the 
mouths of the vessels. The uterus remains 
small, undergoing slight variations in firm- 



84 MANUAL OF OBSTETRICS. 

ness from alternating contraction and relaxa- 
ation. 

Duration of normal labor is longer in 
primiparae than in multiparas, especially 
when past the age of thirty. The average 
length for primiparae is 17, for pluriparas, 
12 hours. The second stage occupies from \ 
to 2 hours. 

Mechanism of Labor in Vertex Pres- 
entations. The mechanism by which the 
fetus passes through the normal pelvis va- 
ries somewhat according to presentation 
and position of the child. 

By presentation we mean that part of the 
fetus which is touched upon vaginal exami- 
nation. The position is the relation which 
certain points of the presenting part bear to 
given points upon the pelvis. Comprehen- 
sive knowledge of the mechanism of labor 
can only be attained by an accurate under- 
standing of the obstetric anatomy of the pel- 
vis and fetus. Head presentations occur in 
95$ of all cases. The four principal posi- 
tions of the head are the first, or left occipito- 
anterior (L. O. A.), in which the occiput is 
situated anterior, and behind the left obtu- 
rator foramen, the long diameter of the head 
being in the right oblique diameter of the 



MANUAL OF OBSTETRICS. 85 

pelvis; the second, or right occipitoanterior, 
(R. O. A.) with the occiput anterior behind 
the right obturator foramen, the long diame- 
ter of the head lying in the left oblique di- 
ameter; the third, or right occipito-posterior, 
(R. O. P.) with the occiput posterior against 
the right sacro-iliac joint, the long diameter 
of the head being in the right oblique line; 
the fourth, or left occipito-posterior (L. O. P), 
having the fetal occiput opposite the left 
sacro-iliac joint, the length of the head being 
in the left oblique diameter. The first is most 
common, the second and third of about equal 
frequency at the brim, while the fourth is 
least common. 

The natural position of the fetus is one of 
general flexion. The spine is convex poste- 
riorly, the arms and thighs against the trunk, 
the forearms and legs flexed upon the respec- 
tive limbs, and the chin brought downward 
toward the chest. When the woman is erect, 
gravity favors a position of the child with 
its back anterior, slightly inclined to the left 
side. The preference which the head shows 
toward the right oblique diameter is influ- 
enced by the presence of the rectum and 
contents in the left posterior part of the pelvis 
shortening the left oblique diameter. The 



86 



MANUAL OF OBSTETRICS. 



position of the head is determined upon ex- 
amination, by observing the relative situations 
in the pelvis of the posterior f ontanelle, sa- 
gittal and lambdoidal sutures, while the 
situation and direction of the coronal and 
frontal sutures, and anterior f ontanelle, when 
they can be reached, aid in diagnosis. The 
amount of flexion of the head is recognized 
by the facility with which the anterior f onta- 
nelle is reached, the higher the fontanelle, the 
greater the flexion. In the progress of all 
vertex presentations, the movements of the 
head are flexion, descent, rotation, extension, 
and restitution or external rotation. 

The first or l. o. a. position. Flexion 
occurs as the vertex engages in the pelvic 
brim. This substitutes the occipito-bregma- 
tic for the occipitofrontal diameter, being 
effected by the resistance of the structures 
about the pelvic brim upon the surface of the 
anterior part of the head which has a greater 
area than the surface of the posterior part, 
the articulation of the head with the body 
being much nearer the occiput than to the 
sinciput. After rupture of the membranes, 
flexion is promoted by the more direct trans- 
mission of pressure, through the spinal col- 
umn upon the posterior part of the head. 



MANUAL OF OBSTETRICS. 



87 



The parturient forces acting, descent of the 
head occurs until the occiput is opposite the 




Fig. 29.— First position of verton. 




Fig. 30.— Movement of flexion. 
lower edge of the obturator foramen, the 



88 MANUAL OF OBSTETRICS. 

forehead being at a much higher level. The 
right parietal bone is slightly lower than the 
left. 

At this part of the pelvic canal the conju- 
gate diameter exceeds in length the trans- 
verse, and rotation of the occiput toward the 
pubes (descent continuing) takes place. The 
occiput lies on the left anterior inclined sur- 
face, the ischial spine directing the sinciput 
upon the right posterior inclined surface. The 
head having descended until it encounters 
the sloping perineal structures, their reflected 
force causes the occiput to turn toward the 
pubic symphysis, the sagittal suture being 
brought to occupy very nearly the antero- 
posterior diameter. 

Descent continuing, the resistance of the 
perineum maintains flexion of the head until 
the occiput escapes beneath the pubic arch, 
the back of the neck lying beneath the bones 
of the pubic arch. 

Extension of the head now occurs, for, as 
the occiput is fixed, the uterine force acts on 
the anterior part of the head. The perineum 
is fully distended, the coccyx is pushed back, 
the sub-occipito-frontal and sub-occipito-men- 
tal diameters pass the outlet of the parturient 
canal, and the head is born. 



MANUAL OP OBSTETRICS. 89 

As extension occurs, the head is expelled in 
a downward and forward direction owing to 
the action of two forces, that of the uterus 
downward, and that occasioned by the resist- 
ance of the perineum, in a forward direction. 




Fig. 31.— Head delivered. 

External rotation or restitution. The head 
now turns toward the right thigh. This is 
owing to the course which the shoulders take 
in descending through the pelvis. The head 
having been born, the shoulders, with their 
transverse diameter corresponding to the long 
diameter of the head as far as the mechanism 
of delivery is concerned, are acted upon by 
the same influences which govern the beha- 
vior of the head in its descent. Their trans- 
verse diameter entering in the left oblique 
line of the pelvis becomes nearly transverse 
when the head is at the outlet. After birth 
of the head, the shoulders rotate into the con- 



90 MANUAL OF OBSTETRICS. 

jugate, which is the longest diameter of the 
outlet, the right shoulder being anterior. 
This directs the child's face toward the right 
thigh, causing the head to perform external 
rotation. 

The shoulders are next expelled, the left, or 
posterior, being usually born first. Sometimes 
they pass simultaneously, or in rare cases the 
anterior may emerge first. The body and 
lower extremities immediately follow. 

Mechanism in the second or R. O. A. posi- 
tion does not essentially differ from that in 
the first position. The long diameter of the 
head is originally in the left oblique diameter 
of the pelvis. The head descends, the occi- 
put rotating anteriorly, and after birth exter- 
nal rotation turns the face toward the left 
thigh. 

Occipito-posterior positions at the brim (R. 
O. P., and L. O. P.) become, in the great 
majority of instances, occipito-anterior posi- 
tions at the outlet, a long rotation occurring 
which brings the occiput from the sacro-iliac 
synchondrosis to the pubic arch. The 
rounded occiput descends until it impinges 
upon the superjacent structures of the sacro- 
sciatic ligaments. The sloping surface there 
encountered tends to turn the occiput toward 



MANUAL OP OBSTETRICS. 



91 



the anterior part of the pelvis. If perfect 
flexion is present, the sinciput will not have 
descended to the ischial spine of its side, and 
there is, therefore, nothing to prevent the 
sinciput from turning posteriorly as the occi- 




Fig. 32.— Third position. 

put rotates anteriorly. Long rotation may 
occur, when flexion is only partial. Then 
considerable time is required to produce 
cranial moulding and more complete flexion. 
In about five per cent of occipito-posterior 
cases the occiput fails to perform anterior ro- 
tation, and the head is born with the face un- 
der the pubic arch. In these cases the peri- 
neum sustains great pressure and distention 
which often leads to extensive rupture. The 



92 MANUAL OF OBSTETRICS 

occiput being born, the back of the neck is 
fixed against the centre of the perineum and 
extension occurs, the face sweeping out 
from beneath the pubes. 

Moulding of the head is the alteration and 
adaptation of its shape to the pelvic canal, 
permitted by the presence of the sutures. 

The caput succedaneum is an oedematous 
condition of that part of the scalp which lies 
in the circle of the os, and, after the head passes 
from the uterus, which lies in the lumen of 
the vaginal canal. Pressure of resisting 
structures, on all parts of the head except op- 
posite the opening of the parturient canal, 
prevents oedema, except at the unsupported 
part of the scalp opposite that opening. 

These phenomena of the mechanism by 
which the head is born in vertex cases are 
subject to some modification when the pelvis 
is very capacious or the head small. 

Management of Natural Labor. 

During the two weeks preceding labor, 
called the preparatory stage, advise systema- 
tic, moderate exercise and the use of nutri- 
tious but digestible food. 

The rectum should be emptied daily and, 
if necessary to secure this, give laxatives such 



MANUAL OF OBSTETRICS. 93 

as the mineral waters, salines, the pil. rhei, or 
senna. Enemata properly administered are 
often of great use. Attention to the bowels 
prevents haemorrhoids and false pains, and 
greatly promotes general health and comfort. 
Clothing should be worn loosely, and restless 
or disturbed sleep obviated by bromide of po- 
tassium or small doses of chloral. 

The skin of the nipples may be hardened by 
daily applications of tannin and glycerine, 
solutions of borax, or nitrate of lead gr. x. to 
glycerine § i. A happy mental condition 
should be encouraged. 

"When summoned to a case of labor attend 
promptly. By so doing you gain the confi- 
dence of the patient, you will always be able 
to meet the charge of neglect if the child is 
born before your arrival, or, if labor is but 
little advancer!, you can recognize and may 
be able correct abnormal conditions, if they 
exist. 

Have at hand a flexible catheter, a prepara- 
tion of ergot suitable for hypodermic use, 
chloroform, stimulants, hot and cold water, 
forceps, needles and silver wire, and hypo- 
dermic syringe. 

First Stage. Examine to ascertain degree 
of dilatation and the character of the os uteri 



94 MANUAL OF OBSTETRICS. 

as to dilatability. Ascertain the presenting 
part by touching it with the finger introduced 
through the cervix. If the os will not admit 
the finger, a vaginal examination of the lower 
uterine segment will show the presence of a 
regularly rounded, firm body if the cephalic 
end of the child presents. The hand depressed 
in the supra-pubic region, if able to appreci- 
ate and grasp this body, confirms the diag- 
nosis. The vaginal examination should be 
conducted with one or two fingers covered 
vaseline, without exposure to the patient who 
lies on her side or back, as the attendant may 
desire. If the os be not readily perceived, 
search may be made for it posteriorly, high 
up toward the sacral promontory. To facili- 
tate the examination, place the hand on the 
abdomen, pressing the uterus into the pelvis 
and carrying the fundus backward. Exam- 
ine in the interval between pains, and again 
during uterine contraction to ascertain the 
amount of protrusion of the amniotic bag and 
whether or not the cervical ring be rigid. 
Palpation of the abdomen will always assist 
in diagnosis of presentation and position. 
Never offer a positive opinion as to the hour 
of delivery. To ascertain this approximately, 
note the frequency and force of uterine con- 



MANUAL OF OBSTETRICS. 95 

tractions, the rapidity with which the cervix 
dilates, the history of previous labor, if the 
one under consideration is not the first, and 
the size and relation of fetal head and pelvis. 
An enema should be given early in labor, for 
nothing annoys patient and physician more, 
during the latter part of labor, than fecal ac- 
cumulation. 

Regularity of pains will be promoted by 
keeping patient out of bed, avoiding, of course, 
fatigue. At the same time caution the patient 
to avoid voluntary, straining efforts under- 
taken with a view to assisting in expulsion. 
During the first stage they are exhausting as 
well as useless. When the os is well dilated, 
if the membranes do not rupture spontan- 
eously, break them with the finger nail, or 
straightened hairpin. 

Until the os is one-half or two- thirds ex- 
panded, the attendant may, in most cases, ab- 
sent himself from the house, watching the pro- 
gress of the case by returning at intervals of 
one or two hours. 

Second Stage. When the os is dilated, the 
position should be definitely ascertained by 
noting relation of sutures and fontanelles to 
each other and to parts of the pelvis. Later, 



96 MANUAL OF OBSTETRICS. 

if the caput succedaneum is formed, it may 
be impossible to determine the position. 

The patient should be allowed to lie down. 
In some countries the position on the side, 
with the nates near the edge of the bed, is 
universally adopted. In this country opinion 
and custom are divided between the dorsal 
and the lateral decubitus. Practitioners 
should accustom themselves to the care of 
women in either position, and select the one 
in which labor makes the better progress in 
each case, being guided somewhat, also, by 
the inclination and custom of the patient. 

She should be judiciously fed occasionally, 
and be instructed in the manner in which 
voluntary, muscular efforts can be best ap- 
plied. During the pains, holding the breath 
and pulling upon some object fixed at arm's 
length toward the foot of the bed will mate- 
rially add to the expulsive force. Early in 
this stage, if pains are infrequent and short, 
it is well to allow the patient to move about 
the floor. Vaginal examinations should be 
made at gradually shortening intervals. 

The condition of the bladder should be 
noted from time to time and the catheter em- 
ployed if necessary. 

Management of the Perineum, when the 



MANUAL OF OBSTETRICS. 97 

head descends upon it, looks to its gradual 
distention, and the final passage of the head 
in as complete a state of flexion as possible, 
the occiput being disengaged from beneath 
the pubic arch before the frontal and facial 
parts sweep the perineum. If the pains at this 
stage are very severe and frequent, tell the 
patient to cease voluntary expulsive efforts. 
To maintain the proper position of the head 
during its expulsion and to support the per- 
ineum, introduce two fingers into the rectum 
and draw the perineum forward. This ma- 
noeuvre, and the pressure of the thumb on the 
vertex, preventing its too rapid descent, se- 
cures complete flexion, while the posterior 
muscular structures of the perineum are 
relaxed and brought forward to the strength- 
ening of the anterior and thinner muscular 
bands. The other hand should at the same 
time assist in disengaging the occiput from 
the pubic arch and from the anterior vulval 
commissure, and until this is accomplished 
the hand with the fingers in the rectum should 
not allow the anterior part of the head to pass 
the perineum. Always avoid direct pressure 
on the perineum, which, while it does not 
give support, increases the danger of its in- 



98 MANUAL OF OBSTETRICS. 

jury by stimulating the uterus to greater ac- 
tion. 

In occasional rare cases, slight lateral in- 
cisions may be indicated to avert a deep cen- 
tral tear. 

After birth of the head, mucus and blood 
should be wiped from the nose and mouth 
and kept from contact with them, lest early 
respiratory efforts introduce this foreign ma- 
terial into the air passages. 

Loosen any coil of funis which may sur- 
round the neck, in order that the circulation 
of the funis may not be interrupted. 

Remembering that the passage of the pos- 
terior shoulder may cause or increase peri- 
neal laceration, direct the shoulders, during 
their birth, forward toward the pubic arch 
and make no undue haste in their delivery 
unless signs of asphyxia are apparent. 

The body speedily follows the shoulders, 
and after the child respires, apply two narrow 
cords, of suitable strength, tightly around 
the funis, the first an inch and a half, the 
second, three inches from the child. Before 
tightening the first ligature, compress the 
portion of the funis next the child, in order 
to displace the gelatine of Wharton from it, 
as the cord will better undergo subsequent 



MANUAL OF OBSTETRICS. 99 

desiccation. Cut between the ligatures and 
remove the child. After birth of the head, and 
during delivery of the body, uterine contrac- 
tion should be aided by the pressure of the 
hand upon the partially emptied uterus. 

Third Stage. After removal of the child, 
the hand should be placed upon the fundus 
uteri and kept there. When five to fifteen 
minutes have elapsed, during which gentle 
manipulation securing uterine contraction is 
kept up, if the placenta is not delivered, its 
detachment and expulsion may be brought 
about by varied and firm uterine compression 
with such slight traction as will direct, not 
withdraw, the placenta. Pressure should be 
made downward and backward in the direc- 
tion of the pelvic brim. Let the placenta 
emerge slowly, in order that no portions of 
the membranes be torn off and retained in 
the uterus. 

After the placenta is expelled, pressure and 
gentle manipulation of the uterus should be 
kept up for half to three-quarters of an hour 
in order to expel coagida, to maintain con- 
traction and to prevent hcemorrhage. This 
close observation of the behavior of the ute- 
rus after delivery should be a part of the 
routine treatment of every case. Ergot 



100 MANUAL OF OBSTETRICS. 

should be given in full dose when the head 
of the child is born, and repeated if the ute- 
rus tends to relax. 

After normal uterine contraction has been 
maintained for the time mentioned, all soiled 
personal and bed clothing should be removed 
and a broad abdominal binder applied, its 
lower border being below the prominences of 
the trochanters to prevent its displacement 
upward. This is comfortable to the patient, 
and by supporting the relaxed abdominal 
parietes prevents any sudden afflux of blood 
to the numerous and large vessels of the ab- 
dominal cavity which might lead to the un- 
pleasant symptoms of collapse and syncope. 

A napkin having been placed between the 
thighs (not against the vulva), if the general 
and local conditions of the patient are good, 
the attendant may leave at any time after an 
hour has elapsed from delivery. He should 
direct the nurse to frequently inspect the 
napkin to ascertain regarding the amount of 
blocd discharged, should direct food to be 
given after the patient has somewhat rested, 
and insist upon quiet. 

THE PUERPERAL STATE. 

During the first twenty-four hours after la- 
bor, keep the patient from excitement and 



MANUAL OF OBSTETRICS. 101 

promote rest. A mind stimulated by the re- 
collection of the events of labor will not 
usually permit refreshing sleep, and a single 
dose of opium, or the use of bromide of potas- 
sium is often advisable. 

Afterpains, usually absent or slight after 
the first and second labors, but present in a 
greater degree after succeeding labors, are 
painful contractions of the uterus. They will 
be less liable to occur if the third stage is pro- 
perly managed. If there be no retained mem- 
branes, or coagula, the uterus is less stimu- 
lated to this painful action. If unavoidably 
present, morphine in small and repeated ad- 
ministrations is necessary, but not until two 
or three hours have elapsed, lest a proper de- 
gree of contraction may fail to occur. 

The bladder should be emptied within eight 
hours after labor. It often happens after con- 
finement that no inclination to urinate is 
experienced by the patient until the bladder 
is so distended that it has lost in great mea- 
sure its contractile power. The catheter 
should be passed within the time mentioned, 
if two or three attempts, on the part of the 
patient, to empty the bladder (the bed-pan 
being used) are ineffectual. The inability to 
urinate may depend upon contusion and 



102 MANUAL OF OBSTETRICS. 

swelling of the meatus urinarius. Whenever 
the catheter has been required, the patient 
should be encouraged to attempt at regular 
periods to pass her urine in the natural way, 
as the continuous use of the catheter may 
cause cystitis. 

The lochia. For several hours after labor, 
there is a vaginal discharge of blood, rather 
more in amount than would attend profuse 
menstruation, which comes from the partially 
closed utero-placental sinuses, and from slight 
lesions of the parturient tract. Small coagula 
having closed the vessels previously laid bare 
by separation of the placenta, the vaginal 
discharge diminishes in amount and consists 
of mucous secretions, decidua, with san- 
guineous admixture from disintegrating clots. 
The discharge becomes less bloody and more 
watery as time advances, until in two or three 
weeks there is little or none. After it loses 
the sanguineous appearance it is found to con- 
sist of epithelium, mucus, debris of decidua, 
blood-corpuscles to which are added later 
fatty particles and pus cells. After it becomes 
watery there may be reappearance of blood 
stains owing to accidental dislodgment of 
some small coagula. 

Changes in the uterus. Retrograde meta- 



MANUAL OF OBSTETRICS. 103 

morphosis of the uterus takes place by fatty 
degeneration of muscular fibres and their ab- 
sorption. Newly developed muscular fibres 
begin to appear three or four weeks after la- 
bor, and involution — if it proceeds without 
interruption— is complete at the end of two 
months. The most rapid reduction in size 
takes place during the second week. The 
weight of the uterus after labor is two pounds, 
at the end of two weeks a little more than 
three-quarters of a pound, and, at the expira- 
tion of six or eight weeks the organ is left 
more rounded and slightly larger than in the 
nulliparous woman. Though most of the de- 
cidua is thrown off after labor, some remains, 
which becomes coated with a fibrinous layer 
at the placental site, and from this a new 
mucous membrane is developed. The vagina 
undergoes involution in a way similar to the 
process in the uterus, and its walls undergo 
contraction, become less flabby, and recover 
their tone. 

The bowels should be moved by a laxative 
by the third day, and regularity in their func- 
tion must be promoted thereafter by laxatives 
or enemata. The first action of the bowels is 
best secured, usually, by a saline, as consider- 
able relief may be obtained to mammary con- 



104 MANUAL OF OBSTETRICS. 

gestion, which occurs about this time, if the 
movements be watery. The compound lico- 
rice powder is also a valuable cathartic for 
post-partum purposes. 

The utmost cleanliness must be obtained 
with reference to the patient's person, per- 
sonal and bed-clothing, attendants, and sur- 
roundings. Judicious bathing is always pro- 
per. The vaginal douche containing some 
disinfectant, twice each day, is comfortable 
to the patient, and increases the chances for 
normal convalescence. 

The diet should beunstimulating and nutri- 
tious. As the secretion of milk commences, 
a large amount of liquid should not be intro- 
duced into the system — simple, easily digested, 
solid food being preferable. 

Nursing and Care of the Breasts. After la- 
bor, unless it is required to stimuate uterine 
contraction by mammary irritation, defer the 
application of the child to the breast until the 
mother has recovered from fatigue. During 
the first forty-eight hours, the child should 
be put to the breast every three or four hours, 
even if there is but little mammary secretion. 
This practice secures, for the child, good ac- 
tion of the bowels as the result of the excess 
of colostrum contained in the early secretion. 



MANUAL OF OBSTETRICS. 105 

Furthermore, it enables us to ascertain the 
capability of the child to suckle, it accustoms 
the mother to handle her child, it develops 
the nipples, and causes a gradual rather than 
a sudden acquisition of the mammary func- 
tion. As the breasts take on their function, 
do not permit them to become painfully swol- 
len, but apply the child to them, or remove 
the milk by gentle rubbing of the breasts 
from periphery toward nipple. If during the 
forty-eight hours occupied in the develop- 
ment of the function, the breasts do not once 
become "caked," but little trouble will be 
experienced subsequently. The slight con- 
stitutional disturbance which is liable to 
occur when a large extent of gland structure 
is suddenly and greatly congested, will be 
modified by the management described. Tho 
nipples should be bathed and dried after each 
nursing, the danger of excoriation and fissure 
being thus lessened. The child should not be 
applied to the breast more frequently than 
every two hours. 



106 



MANUAL OF OBSTETRICS. 



1. Natural Labor. 



o 

CD 

s 



a 
4§ 



o 

I 

|o 

C3 <D 

i 



Disturbances of j g^ tate - 
Maternal Forces, { gZta*. 

| Obstructions* in soft 
parts. 
Deformity of Pelvis. 

Mai presentation . 
Multiple pregnancy. 
Excessive developni't. 
Monsters. 
Hydrocephalus. 
Premature ossification 
Tough membranes. 
Dry labor. 
Long or short cord. 
Multiple presentation, 
f Accidental. 

ti~~*~~-'u*>~~ \ Unavoidable. 
Hsemorrhage.^ Post partum . 

[ Secondary. 
Prolapse of funis. 
Retention of placenta. 
Inversion of uterus. 
Rupture of uterus. 
Lacerations of cervix and perin'm. 
Puerperal convulsions. 
Sudden death of mother. 



Abnormal 


condition of 


maternal 


pas- 


stages. 




O 




-M 




bQ 


co 


.9 




"3 


CD 


•i— i 


+3 


c3 


& 


13 

CD 


8- 


£U 


CD 




fl 


CO 


•rH 


CD 


H 


CO 


CD 


3 




o 





♦Obstructions in soft parts, rigid os, adhesions, can- 
cer, tumors, cystocele, calculus, faeces, hymen, peri- 
neum, thrombus, oe dema, antepartum hour-glass con- 
traction. 



CHAPTER VI. 

PRECIPITATE AND TEDIOUS LABORS. — OBSTRUC- 
TIONS IN MATERNAL SOFT PARTS. — DE- 
FORMITY OF THE PELVIS. 

Precipitate Labor is of short duration, 
characterized by violent and prolonged ute- 
rine contractions following in quick succes- 
sion, at times the condition being one of tonic 
contraction. 

Dangers to mother are those of laceration 
of cervix, rupture of perineum, and even of 
the uterus, extrusion of the uterus, shock and 
haemorrhage from sudden emptying of the 
uterus, and mental excitement from physical 
causes, or from lack of conditions suitable to 
confinement, as in delivery in public places. 
Dangers to child are from asphyxia, if the in- 
tervals between uterine contractions are too 
short to allow of restoration of normal utero- 
placental circulation, or from injury if deliv- 
ery occurs in places unprepared for the recep- 



103 MANUAL OF OBSTETRICS. 

tion of the child. Both mother and child are 
exposed to danger if there be malpresentation 
and resulting delay. 

Causes are a peculiar irritability of the ner- 
vous system controlling functions of the gen- 
erative tract, and roomy pelvis with compara- 
tively small child. Women sometimes possess 
this peculiarity of temperament by inherit- 
ance, and it would be indicated also by ner- 
vous excitement at menstruation. 

Symptoms. In addition to the overwhelm- 
ing action of the uterus, the voluntary muscles 
take upon themselves, in a reflex way, expul- 
sive action quite beyond the volition of the 
patient. 

Treatment may be preventive if a tendency 
to precipitate labor is known to exist. Dur- 
ing the last month of pregnancy, patient 
should never be far away from home. On 
occurrence of pain she should seek her l>ed, 
and mental excitement should be avoided. 
"When labor of precipitate character is estab- 
tablished, chloroform will modify tli3 force 
of uterine and voluntary muscular action. 

Tedious Labor, from irregular uterine 
force. The immediate cause in most instan- 
ces is uterine inertia. This may be produced 
or encouraged by abnormal uterine structure, 



MANUAL OF OBSTETRICS. 109 

over-distention of the uterus by excess of 
liquor amnii, or by twin pregnancy, misdi- 
rected force, want of dilatability of cervical 
region, lack of nerve stimulus, as in those 
enervated by fashionable dissipation, by sed- 
entary habits, by life in warm climates, by 
frequent child-bearing, by bad morale or 
melancholia. In labor commencing as nor- 
mal, partial uterine exhaustion may arise 
from delay produced by any obstruction, 
by distended bladder, intestinal disturbance, 
or emotion. 

Tedious labor is characterized by weak 
pains of short duration. They may occur 
regularly at long intervals, or the intervals 
between them may vary irregularly in length. 
This unrhythmical, inefficient uterine action 
may be limited to a part of the labor, and 
may be present in the first or second stage, or 
throughout both stages. 

Symptoms. Delay occurring in the first 
stage, which is under the control of the sym- 
pathetic system, may be much protracted 
without producing exhaustion, though irreg- 
ular sleeping and eating, with more or less 
mental annoyance, will bring about sense of 
fatigue. There is usually anxiety, increasing 
in multipara, and apathy in primiparse. A 



110 MANUAL OP OBSTETRICS. 

tardy second stage, however, should be 
watched closely, for after a time the pulse 
and temperature will slowly rise, and such 
symptoms as dry or coated tongue, gastric 
irritability and general restlessness will super- 
vene. 

Treatment. Remove, if possible, the cause 
of the condition. Rupture of membranes in 
over-distention, straightening the uterus if 
its axis is not that of the pelvic brim, reliev- 
ing a distended bladder may be attended by 
immediate improvement. 

If partial or complete inertia uteri be the 
chief cause of tedious labor, endeavor to 
rouse the uterus. To do this, use enemata of 
stimulating character, or of cool water, douche 
to the cervix, manual irritation or pressure of 
the uterus through the abdomen, quinine, er- 
got when labor is well advanced in the second 
stage. Emotional influences may be removed 
by chloral or chloroform. Failing to remedy 
the condition by these means, employ instru- 
mental aid according to the stage of labor, as 
by the Barnes dilators or the force p 

Powerless Labor is that condition which 
may result after a protracted second stage, if 
instrumental aid is not rendered. It is one of 



MANUAL OF OBSTETRICS. Ill 

general prostration with, of necessity, com- 
plete inaction of the uterus. 

The pulse becomes quick and irritable, 
tongue dry, temperature elevated, skin dry, 
and face pinched in expression. There will 
be mental confusion, delirium, and gastric 
irritability. The vagina becomes hot and dry. 
The fetal heart-sounds are feeble or absent. 

Prognosis grave for mother and child. 

Treatment. — No woman should ever be 
allowed to reach this condition. When it ex- 
ists, judicious stimulation, with highly nutri- 
tious and concentrated food should be em- 
ployed until such reaction shall be brought 
about that operative aid to delivery may be 
tolerated. Then the child must be delivered 
while watchful constitutional support is con- 
tinued. When labor is survived, great care 
is necessary to avert hemorrhage, to over- 
come extreme prostration, and to prevent in- 
flammations of pelvic organs and septicaemia. 

OBSTRUCTIONS IN MATERNAL SOFT PARTS. 

Rigidity of the cervix, most commonly 
met with when membranes rupture early in 
labor, may be spasmodic, owing to pressure 
and irritation of the cervix by the presenting 
part, or owing to the constitutional peculi- 



112 MANUAL OF OBSTETRICS. 

arity of a nervous or emotional temperament. 
Rigidity of the cervix may result from a pre- 
ponderance of fibrous or cicatricial tissue 
over normal muscular structure. It may re- 
sult from imperfect dilating action of longi- 
tudinal muscular fibres extending upward 
from their cervical origin. In some cases, 
when the membranes are intact they may 
fail to descend to form a dilating pouch, owing 
to their unusually close adhesion to the lower 
uterine segment. There may be co-existence 
of several of these causes. Examination may 
reveal the cervix thick and fleshy, thin with 
cord-like edge, or nodulatsd and hard. 

Treatment. — When the spasmodic element 
is noted, use chloral, gr. xv. every half -hour 
until 3 i. has been given, or morphia, in doses 
of gr. £ every hour or two. Belladonna and 
atropia, by local application or injection, 
have been recommended, but are of doubtful 
value. Chloroform is of some benefit, but 
for several reasons its use in the first stage of 
labor is undesirable. Local measures, from 
which to select, are the prolonged douche to 
the cervix, digital dilatation, the ivater-bags 
of Barnes, and the making of several small 
incisions. (Edema of the cervix, usually af- 
fecting the anterior lip, caused by pinching 



MANUAL OF OBSTETRICS. 113 

of the upper part of the cervix between 
the head of the child and pubic bones, is 
more common when the woman keeps the 
dorsal position during the first stage. Treat- 
ment is to maintain digital pressure on the 
oedematous cervix. 

Carcinoma of the cervix, when an indurated 
and thickened condition is present, may be a 
serious obstacle to delivery. The os may be 
so undilatable as to require incision of the 
cervix and such obstetric operations as are 
necessary when the uterine outlet cannot be 
rendered sufficiently large to allow of spon- 
taneous passage of the child. Even Cesar- 
ean section has been required. Dangers to 
the mother are those attending division of 
the diseased tissue— notably that of hemor- 
rhage — with the usual dangers of operative 
procedures. Happily, women afflicted with 
cancer of the cervix do not often conceive, 
or, if pregnant, generally abort. 

Ante-partum hour-glass contraction of the 
uterus, though rare, is so difficult to overcome 
that forceps, version, embryotomy, and even 
Caesarean section may be rendered necessary. 
It is serious in its results to the mother, and 
more so to the child, causing an impediment 
to delivery from tetanoid contraction of bun- 



114 MANUAL OF OBSTETRICS. 

dies of transverse or of oblique uterine fibres, 
which grasp and retain the fetus in utero. 
Ancesthetics have but little relaxing effect. 
The production of emesis is useful, though 
some of the obstetric operations are usually 
required. 

Cicatricial narrowing and closure of the os 
uteri or of the vagina requires appropriate 
surgical treatment. 

Tumors of the uterus, if polypoid and hang- 
ing from the cervix, should be twisted off or 
removed by the ecraseur. Tumors of the body, 
usually fibroid, do not often offer serious ob- 
stacle to labor other than to interfere with nor- 
mal uterine action and to predispose to hemor- 
rhage after delivery. Fibroid tumors of the 
cervical zone should be pushed upward out 
from the pelvis if possible. If this is impos- 
sible, they must be removed by enucleation 
or by the ecraseur. 

Cystic tumors of the ovary which can- 
not be raised out of the pelvic cavity 
should always be punctured if of such 
size as to offer any impediment to labor. 
In cases where the head can be crowded past 
without their evacuation, they sustain such 
bruising as to lead to inflammation and slough- 
ing, which is prone to extend to neighboring 
tissues and result seriously, if not fatally. 



MANUAL OF OBSTETRICS. 115 

Vaginal cystocele should not be mistaken 
for a protruding pouch of membranes, a tu- 
mor, or an hydrocephalic fetus. No difficulty 
from the presence of cystocele will be encoun- 
tered if a soft male catheter be used early and 
often enough to prevent accumulation of 
urine, and the empty bladder be pushed above 
the child's head. If early attention has not 
been rendered, and the catheter cannot be 
passed, puncture with the aspirator needle 
should be performed. 

Vesical calculus should be pushed upward 
from the pelvic cavity before the head is al- 
lowed to descend. If this cannot be done, 
remove it through the urethra after dilating 
that canal, or by vaginal lithotomy. 

Fecal impaction should be recognized and 
treated as early in labor as possible, enemata 
or the scoop being employed. 

Fibrous hymen should be incised or ex- 
cised. 

Rigidity of the perineum may be owing to 
unusual thickness of its normal struc- 
ture, to cicatricial hardness left from former 
labor, or to spasmodic action of the muscles, 
in which spasm the levator ani sometimes 
participates to a marked degree. Though 
this rigidity rarely seriously obstructs labor, 



116 MANUAL OF OBSTETRICS. 

it may favor rupture of the perineal body- 
when uterine force finally overpowers it. 
Rigidity will best be overcome by gradual 
distention of the perineum by the alternately 
descending and receding head. 

Chloroform is of great relaxing efficacy. If 
laceration seems inevitable, lateral incisions 
made with the bistoury may prevent a deep 
central tear. 

(Edema of the vulva, generally associated 
with albuminuria, may be relieved by making 
numerous punctures through the skin which 
allow the serum to transude. 

Hematocele, or blood-tumor resulting from 
rupture of some vein of the bulbi vestibuli, or 
of the adjacent venous conglomerations, may 
be confined to the labium or may dissect its 
way in the cellular tissue around the vagina 
until there be a large mass offering complete 
obstruction to the exit of the child. 

Varicosity of the veins of the labia favor 
the accident, which is most likely to occur 
from pressure of the head when near the vul- 
va. If the tumor cannot be reduced in size 
by pressure, it should be incised, the clots 
turned out, and immediately after labor 
every attention given to prevent haemorrhage. 
Packing the cavity, previously occupied by 






MANUAL OF OBSTETRICS. 117 

the haematic effusion, with lint soaked in a 
solution of liquor ferri subsulphatis will be 
necessary. Frequently applied antiseptic 
dressings are very important subsequently. 

DEFORMITY OF THE PELVIS. 

The pelvis is deformed when one or more of 
its diameters vary from the normal standard. 

Causes may be congenital, from injury, or 
from disease. 

Principal varieties are: — 1. Rachitic pelvis, 
shortened an tero- posterior diameter. 2. Mal- 
acosteon pelvis, shortened transverse diam- 
eter. 3. Oblique deformity. 4. Infantile 
pelvis. 5. Male pelvis. 6. Pelvic exostoses. 
7. Pelvis aequabiliter justo-minor. 8. Pelvis 
aequabiliter justo-major. 9. Pelvis deformed 
by spinal curvature, flattened sacrum, hip- 
joint disease, anchylosis at the sacro-iliac 
joint, or fracture. 

Rachitis is a disease of early life attended 
by irregular softening of the bones chiefly 
affecting cartilaginous portions by tardy de- 
posit of lime salts. As the disease occurs 
prior to the common age at which children 
walk, and leads to more or less postponement 
of that exercise, the deformity of the pelvis 
produced by it is such as would be expected 



118 MANUAL OF OBSTETRICS. 

as the result of the constant sitting or recum- 
bent postures. The pelvis being softened in 
parts and capable of alteration in shape, be- 




Fig. 33.— Rachitic pelvis. 
comes narrowed in the conjugate diameter 
from downward pressure of the weight of the 
body, and there being no counter-pressure by 
the heads of the f emor i, the transverse dia- 
meter is not narrowed. The transverse dia- 
meter may even be slightly increased, for the 
weight of the body pressing the sacrum for- 
ward causes traction on the sacro-iliac liga- 
ments, and, by their insertion in the ilia, the 
tendency of the pelvis will be to widen later- 
ally. The deformity of the rachitic pelvis is 
chiefly at the brim. 

The figure-of-eight pelvis is usually of 
rachitic origin and is produced by forward 



MANUAL OF OBSTETRICS. 119 

displacement of the sacrum with backward 
depression of the pubes caused by traction of 
the recti muscles. 

Osteo-malacia rarely occurs in this country ; 
it is a disease by which the pelvis is softened 
after the person affected has the power of 
locomotion, and therefore pressure of the 
femora upon the ilia leads to transverse nar- 
rowing. The triangular pelvis is developed 
in this way when there is added forward pro- 
jection of the sacrum from rickets or other 
cause. 

The oblique pelvis may result when osteo- 




Fig. 34.— M alacosteon pelvis, 
malacia has affected one side of the pelvis 
more than the other. Another cause for the 
oblique pelvis is premature ossification of one 
sacro-iliac joint preventing pelvic develop- 



120 MANUAL OF OBSTETRICS. 

ment of the corresponding side. The growth 
of the unaffected half of the pelvis carries the 
symphysis pubis away from the median line 
toward the opposite side. The sacrum may 
be depressed by the custom of carrying heavy 
weights on the shoulders. 

Spondylolisthesis consists in a forward pro- 
jection of the fourth and fifth lumbar verte- 
brae, and while the pelvis may be normal, the 
child is prevented from reaching readily the 
pelvic brim. To allow of this deformity, there 
must have been previous inflammation and 
softening of vertebrae and intervening car- 
tilage, to which may have been added the car- 
rying of heavy weights on the shoulders. 

The infantile or undeveloped pelvis is one 
retaining the characteristics of the pelvis of 
youth. The conjugate is long, in proportion 
to the transverse diameter, the pubic arch 
being narrow. 

The male or funnel-shaped pelvis, composed 
of bones heavier and thicker than usual in the 
female, has a sacrum with but little concavity, 
and has approximated ischial tuberosities. 

Exostoses, osseous tumors, and the callus 
from former fractures may obstruct the pel- 
vis, or may so press upon the parturient uterus 



MANUAL OF OBSTETRICS. 121 

as to injure its structure and lead to inflam- 
matory softening and rupture. 

The pelvis cequabiliter justo-minor is sym- 
metrical, and proportionately contracted in all 
its diameters. It is found in dwarfs and in 
those who attain puberty and complete pelvic 
ossification at an early age. Very early men- 
struation may excite suspicion of its exis- 
tence. 

The pelvis cequabiliter justo-major is sym- 
metrical with all its diameters increased 
above the standard. 

. The flattened pelvis is produced by sinking 
downward and inward, without tilting, of the 
sacrum. The narrowing is found, therefore, 
in the course of the pelvic canal. Compensat- 
ing increase of the transverse diameter is 
common. 

Transverse narrowing of the pelvie brim is 
not common and most frequently arises from 
posterior curvature of the spinal column in 
the lumbar region. 

Anchylosis of both sacro-iliac joints pro- 
duces a pelvis elongated in the conjugate and 
diminished in the transverse diameter — the 
Robert's pelvis. 

Dangers to mother are from prolonged labor 
due to mechanical obstruction to deliverv, 



122 MANUAL OF OBSTETRICS. 

often favored also by failure of correspondence 
of the axes of uterus and pelvis, the uterus 
having commonly an obliquity, because its 
lower segment cannot settle into the pelvic 
brim. Danger is increased by obstetric opera- 
tions required to overcome the obstruction to 
labor, and to correct malpresentations, which 
are common. Rupture of the uterus may 
occur, owing to prolonged friction of uterine 
tissue upon some point of bony deformity, and 
to violent uterine action occasionally met 
with during nature's attempt to complete par- 
turition. Sloughing of maternal soft parts 
may result from prolonged pressure of the 
child upon them. Metritis, parametritis, 
and perimetritis often occur. 

Dangers to child arise from compression of 
its vital parts during its birth ; from prolapse 
of the funis, which often arises from failure 
of the presenting part to occupy and fill the 
the irregular pelvic brim ; and from such 
operative procedures as forceps, version, and 
craniotomy, which may sacrifice its life. 
Depressions of the skull, which may be per- 
manent, are often caused by some obstructing 
bony part. 

Diagnosis of Pelvic Deformity. — The con- 
dition may be suggested by history of injury 



MANUAL OF OBSTETRICS. 123 

or disease affecting the pelvis or other osseous 
structures, or of previous difficult labors. 
During pregnancy, early quickening may ex- 
cite suspicion, contact of the uterus with the 
abdominal wall occurring at an early period, 
the uterus being too large to remain in the 
contracted pelvis. Later in pregnancy, there 
may be unusual shape of the abdominal 
tumor produced by its falling greatly forward 
(pendulous abdomen), or caused by irregular 
presentations. 

Pelvimetry, or the measuring of pelvic diam- 
eters, is of service in detecting the greater de- 
grees of deformity, while the presence of lesser 
degrees may be appreciated, and approxi- 
mately estimated. External measurements as 
accurately indicating the degrees of contrac- 
tion of the pelvic cavity are practically value- 
less. The three diameters to be noted, with 
their average normal measurements, are: that 
between the anterior superior spines of the 
ilia, IO5 inches ; that between the crests of 
the ilia, 11J inches; and the external conju- 
gate, from a point below the spine of the last 
lumbar vertebra to the upper anterior border 
of the symphysis pubis, 8 inches. Any great 
variation from these figures calls for internal 
pelvimetry, which is better performed by the 



124 MANUAL OF OBSTETRICS. 

finger in the vagina than by instruments. 
In a normal pelvis the promontory of the 
sacrum can be touched with difficulty, or not 
at all. The diagonal conjugate is the diame- 
ter from the sacral promontory to the lower 
border of the symphysis pubis, and if the 
former point can be reached, this diameter 
can be measured accurately by the index 
finger. Deduct f of an inch from this, and 
the conjugate of the brim is known. The 
transverse and conjugate diameters of the 
cavity and the outlet, and the angle of the 
pubic arch can be approximately estimated by 
the finger. Supra-pelvic examination through 
relaxed abdominal walls in the non-pregnant 
woman will materially aid in diagnosis. 
Mechanism by which the head may be born in 
the equally contracted pelvis differs from the 
normal in that flexion has to be extreme dur- 
ing the entire passage of the head. In a 
rachitic pelvis the bi-temporal diameter lies 
in the conjugate of the brim, semi-flexion 
being present. The parietal bone lying 
against the anterior pelvic wall remains 
fixed, and the parturient forces depress the 
posterior parietal bone past the sacral pro- 
montory. The occiput is then depressed un- 
til it reaches the plane of the cavity. From 



w* 



MANUAL OF OBSTETRICS. 125 

this time the usual movements of the head 
take place. Other varieties of pelvis produce 
various deviations from normal mechanism. 

Treatment. — When the conjugate of the 
brim is not less than 3£ inches, employ for- 
ceps or version, the latter operation being 
especially suited to cases seen early in labor 
when the transverse diameter is ample. 

Version may deliver a living child when 
the conjugate is narrowed to 2J inches, though 
three inches is the limit usually placed. 
Choice must be made between craniotomy, 
laparo-elytrotomy, Ccesarean section, and 
Form's operation in the degrees of deformity 
greater than the above, the requirements of 
each case being studied. 

Induction of Premature Labor is a valuable 
method of treatment when pelvic deformity 
is previously known to exist. It should be 
performed at the 

30th week when the conjugate is 2£ inches. 



33d 


tt 


t< 


a 


a 


" 3 


a 


35th 


a 


a 


a 


a 


11 3± 


a 



CHAPTER VII. 

UNNATURAL LABOR DUE TO MALPRESENTA- 
TIONS, TWINS, AND TO OTHER CONDITIONS 
PERTAINING TO THE UTERINE CONTENTS. 

Breech Presentations.— Under this head 
are included knee and footling cases. The 
breech presents once in 50 labors; the foot 
once in 100; and the knee once in 1,000. 

TJie principal positions of the breech are 
the 1st, left sacro- anterior, L. S. A., the sa- 
crum being directed toward the left obturator 
foramen; 2d, right sacro-anterior, R. S. A., 
the sacrum toward the right obturator fora- 
men; 3d, right sacro-posterior, R. S. P., the 
sacrum against the right sacro-iliac joint; 
4th, left sacro-posterior, L. S. P., sacrum 
against the left sacro-iliac joint. In footling 
a,nd knee cases the sacrum, assumes in time 
one of these four relations to the pelvic parts. 
The first and second positions (dorso-anterior) 
are more common than the third and fourth 



MANUAL OP OBSTETRICS. 



127 



(dorso-posterior), because the convex back of 
the child is better adapted to the abdominal 
parietes than to the projecting bodies of the 
convex spine. In footling cases the feet and 
breech are originally situated side by side 




Fig. 35.— Knee Presentation. 



in the lower uterine segment, the foot or feet 
being extended later and presenting at time 
of labor. The rarity of knee presentation is 
owing to the fact that an extended thigh 
makes the fetus embarrassingly long for the 
uterine cavity. 



128 



MANUAL OF OBSTETRICS. 



Causes of breech presentation are excess of 
liquor amnii, lax uterine walls (easily allow- 
ing fetal movements which may substitute 
the breech for the head), deformed pelvic 
brim (to which the head may not be well 




Fiq. 36.— Presentation of the breech. 

adapted), and prematurity, or death of the 
fetus. 

Diagnosis. — The membranes, when unrup- 
tured, constitute a more cone-shaped pouch 
than when the head presents. Between the 
pains, if the fetus can be depressed, and the 



MANUAL OF OBSTETRICS. 129 

finger carried upward — avoidance of undue 
violence being necessary — the yielding tissue 
of the buttocks can be felt, the sensation to 
the finger differing much from that of the 
firm head. External palpation will reveal 
the firm, globular head of the child as absent 
from the supra-pubic region, and present in 
some part of the fundus uteri. The fetal 
heart will be heard, usually, at a level with, 
or above the umbilicus. After rupture of 
the membranes, the examining finger recog- 
nizes the sacrum with its spinous processes, 
coccyx, the tubera ischii, and intervening 
cleft with anus. The genital organs can be 
recognized, it being remembered that the 
scrotum in a male child may be greatly 
swollen. The absence of the alveolar ridge 
excludes the idea of the finger in the mouth, 
while the presence and escape of meconium 
assists in the diagnosis. The foot will not be 
mistaken for the hand if it be remembered 
that the former is more narrow and thicker, 
with the toes parallel and in a direct line 
with the sole. The knee differs from the 
elbow, in having the patella and two tube- 
rosities with a central depression, the elbow 
having the prominent olecranon. The shoul- 
der, with which the knee might be con- 



130 MANUAL OF OBSTETRICS. 

founded, has one rounded prominence, with 
clavicle and spine of scapula in close proxi- 
mity. 

Prognosis to mother is somewhat less 
favorable than in vertex presentation. One 
child in six or eight dies. The prin- 
cipal source of danger is from compres- 
sion of the funis between the pelvic wall 
and the fetal head, which interrupts the 
utero-fetal circulation. When this impedi- 
ment to the circulation is complete for 
more than two or three minutes, the child 
will be still-born, as its only supply of 
aerated blood comes through the funis. 
In breech cases, the placenta may be com- 
pressed between the uterus and the child's 
head, or may be partially cast off when the 
size of the uterus is reduced from descent of 
the buttocks and trunk. In these ways, the 
supply of oxygenated blood to the fetus may 
be fatally limited. 

Mechanism. — The long diameter of the 
breech enters the pelvis in one of its oblique 
diameters, rotating into the conjugate di- 
ameter when nearly at the outlet. The an- 
terior hip becomes fixed behind the pubes, 
and, by a movement similar to extension 
when the vertex presents, the posterior hip 



MANUAL OF OBSTETRICS. 131 

is born first, to be speedily followed by the 
other. The body and shoulders descend, the 
latter entering in the same diameter at first 
occupied by the breech. If, from needless 
and hasty interference by the attendant, or 
from hitching of the arms on bony or soft 
parts, the arms become extended beside the 
head, they require to be brought down. The 
anterior shoulder becoming fixed behind the 
pubes, that which is posterior is born first. 

The head enters the pelvis with its occipito- 
frontal diameter in the opposite oblique di- 
ameter of the pelvis to that previously occu- 
pied by the hips. The parturient force 
acting from above, tends to keep up flexion, 
and the occiput is the last part delivered. 
In sacro-posterior cases, a long rotation of 
the head generally occurs, bringing the occi- 
put beneath the pubes, this being the situa- 
tion which it always reaches in sacro-anterior 
cases. In a comparatively small number of 
sacro-posterior cases, the head fails to rotate, 
and the occiput descends in the hollow of the 
sacrum. 

Treatment. — The general principles of 
treatment are to leave to nature, or even re- 
tard, the delivery of the child until a time is 
reached at which the circulation of the funis 



132 MANUAL OF OBSTETRICS. 

may be embarrassed by pressure of the head; 
then complete delivery of the child with the 
utmost speed. By avoiding haste during de- 
scent of the buttocks and body, cautioning the 
patient to refrain from voluntary effort, the 
parts have time to be dilated and prepared 
for the passage of the head, and the arms are 
less likely to ascend. 

When the umbilicus reaches the vulva, a 
loop of funis should be brought to view, ex- 
amined to ascertain the condition of its 
circulation, and the ascending portion placed 
in that part of the pelvis which will be least 
occupied by the head which is about to de- 
scend. 

If, as often happens, the arms do not de- 
scend with the thorax of the child, but 
ascend by the sides of the head, the posterior 
arm should be quickly brought down by the 
finger of the attendant carrying the arm for- 
ward over the side of the child's face. The 
anterior arm should be released in a similar 
way. Encourage the patient to make violent 
bearing down efforts, direct an assistant to 
make downward manual pressure upon the 
uterus, and, lifting the child's body forward 
towards the mother's abdomen, deliver the 
head. To facilitate this, maintain its flexion 



MANUAL OF OBSTETRICS. 133 

by fingers placed on each side of the child's 
nose or in its mouth, while the fingers of the 
other hand press the occiput upward. If 
there is delay in the escape of the head, mu- 
cus and blood should be wiped from the face, 
and the perineum retracted sufficiently to 
permit of respiratory acts which may save 
the child's life. If the head cannot be de- 
livered in the way described, apply the 
forceps. 

Impacted breech cases. — When the breech 
becomes impacted in the pelvis, bring down 
one leg, if possible, to lessen the circumfer- 
ence of the presenting part. If this cannot 
be done, pass a strip of muslin over one leg 
at the inguinal region and use it to obtain ad- 
ditional traction power. Never use the blunt 
hook on a living child. 

In sacro-posterior cases when anterior rota- 
tion of the occiput does not occur, the occiput 
impinges upon the perineum and usually the 
face is born first, beneath the pubes. In rare 
cases the head becomes fully extended and the 
face is born last. In either f vent, chiefly in 
latter, there is greater delay in delivery of 
the head and much danger of injury to the 
perineum. Direct the child's body backward 
toward the mother's sacrum and strive to 



134 MANUAL OF OBSTETRICS. 

maintain flexion of the head upon the thorax 
during the traction required for delivery. 

In footling and knee cases it is especially im- 
portant that descent should not be hastened 
lest the maternal parts should be unprepared 
for passage of the head. 

Face Presentations occur once in 230 
labors, the condition being one of extreme 
extension of the head. 

Causes, as far as known, which lead to 
separation of the chin from the chest are: — 
unusual length of the posterior part of the 
head (doiicho-cephalus), hitching of the occi- 
put upon structures at and near the pelvic 
brim, and extreme lateral obliquity of the 
uterus. If the first of these conditions exists, 
the latter two causes are more operative. 
Other lesser causes, such as would prevent 
good flexion of the head, are coiling of the 
funis about the neck, or unusually full chest 
of the child. 

In order that uterine obliquity may have an 
influence in producing face presentation, the 
child's back must be directed to the side 
to which the uterus deviates. Face presenta- 
tions arise at, or a few days before labor. 

Varieties. — The four positions of the face at 
the brim are: — 



MANUAL OF OBSTETRICS. 



135 



Mento-posterior. 



1st Position. 



Face in right 

oblique diameter. 

Forehead to left 

foramen ovale. 



2d Position. 

4 « » 

Face in left 
oblique diameter. 
Forehead to right 

foramen ovale. 



Mento-anterior. 



3d Position. 



4th Position. 



Face in right 
oblique diameter. 
Forehead to right 
sacro-iliac joint. 



Face in left 
oblique diameter. 
Forehead to left 
sacro-iliac joint. 



It will be seen that these positions corre- 
spond to those of the vertex, the first position 
being effected by extension of the head where 
the first position of the vertex had existed, 
the second position of the face from the sec- 
ond of the vertex, etc. The relative fre- 
quency of the positions of the face is still a 
matter of dispute. 

Mechanism. — During labor, no matter what 
the position may be, in the mechanism of 
descent, the long diameter of the face cor- 
responds to the long diameter of the vertex, 
while the chin corresponds to the occiput, the 



136 



MANUAL OF OBSTETRICS. 



usual parturient influences being brought to 
bear during descent and rotation. In the 
third and fourth positions, the chin undergoes 
a small degree of rotation, being turned from 
the foramen ovale, at which it was originally- 
found, to the pubes. In the first and second 
position the chin in the very great majority 




Fig. 37.— Second position in face presentation. 



of cases rotates finally beneath the pubes, 
passing (as is common with the occiput in oc- 
cipito-posterior vertex cases) from the sacro- 
iliac synchondrosis, through a long rotation. 



MANUAL OF OBSTETRICS. 



137 



This may not occur until the chin impinges 
upon the perineum, or may be effected by the 
ischial spines which direct the chin forward 
upon one anterior inclined surface, while the 
sinciput rotates backward on the posterior 




Fig. 38. — Rotation forward of chin. 



inclined surface of the opposite side into the 
hollow of the sacrum. 

In rare cases the chin fails to rotate ante- 
riorly, and, if the child is of average size, we 
will then have to deal with an impaction of 
the head in the pelvis bey ond the possibility of 
spontaneous delivery. In all face cases, the 



138 MANUAL OF OBSTETRICS. 

first step in the mechanism by which the head 
passes the pelvic canal is most complete exten- 
sion, while the final delivery of the head from 
the vulva requires flexion before external rota- 
tion, or restitution, occurs. The various 
movements of the head are, therefore, com- 
plete extension, descent, rotation, flexion, and 
external rotation. 

Diagnosis of face presentation will be made 
on vaginal examination, by which the parts of 
the face will be appreciated. The supra-orbi- 
tal ridges and malar bones will be felt as 
well as the eye, nose and mouth, the orbits 
and alveoler ridges resembling nothing con- 
nected with the breech. Previous to rupture 
of membranes, the diagnosis can be made. 
The presenting part will be found rather high 
in the pelvis, though readily depressed by su- 
pra-pubic pressure. 

Prognosis is less favorable than in vertex 
cases, owing to the increased diameters 
which have to pass the pelvic canal when the 
head is in a condition of extension. The 
mother is exposed to the dangers which at- 
tend delayed labor. Prolonged pressure by 
the head, or its impaction, may produce 
serious local injuries, such as sloughing, fis- 
tula, or lacerations. If descent of the child 



MANUAL OF OBSTETRICS. 139 

occurs with the chin anteriorly, unaided 
delivery will generally take place, though the 
mortality to the child is one in ten. The 
pressure exerted on the vessels of the neck 
may lead to fatal congestion of the brain. 
If born alive, the child's face will be greatly 
disfigured, for a day or two. 

When the chin fails to rotate out of the hol- 
low of the sacrum, the child, if of ordinary 
size, will almost inevitably perish. 

Treatment. —During the first stage of labor, 
carefully avoid rupture of membranes. 

In the majority of labors, a stage is reached 
when we have the os nearly or quite dilated, 
membranes unruptured, and the presenting 
part movable at the pelvic brim. Properly 
applied efforts at this time will easily convert 
the face into a vertex presentation, in most 
cases. To do this, give chloroform, pass the 
hand into the vagina, and with the fingers 
grasp the occiput and draw it downward. 
The other hand will give aid by external mani- 
pulation. The attempt will sometimes suc- 
ceed after rupture of the membranes. If the at- 
tempt is successful, the case must be watched 
until after the engagement of the head, 
for there will be some tendency to a return of 
the face presentation. 



140 MANUAL OF OBSTETRICS. 

In cases in which labor is advanced, and 
engagement of the face has taken place, no in- 
terference is necessary as long as there is 
reasonable hope of favorable termination, 
except that, in mento-posterior cases, there 
should be an endeavor to accomplish long 
rotation of the chin anteriorly, by aid of the 
finger which shall either press the chin for- 
ward or press the forehead backward and up- 
ward, the operator remembering that rotation 
may occur when the head is quite low in the 
parturient canal. The forceps may be requir- 
ed to terminate labor. 

In mento-posterior cases with no anterior 
rotation of the chin, forceps or craniotomy 
will usually be required. 

In all examinations and manipulations, 
care must be taken to avoid injury to the 
delicate parts of the face. 

Brow Presentation is a presentation of 
the frontal bones, the examining finger being 
able to appreciate the anterior fontanelle at 
one border of the cervix, while at the opposite 
side the orbits and base of the nose may be felt. 
It is usually converted spontaneously into 
vertex or face presentation. If it fail to un- 
dergo one of these changes, great difficulty 
will attend delivery, for the longest diameter 



MANUAL OP OBSTETRICS. 141 

of the head must pass the several planes of 
the pelvis. 

Treatment may be directed to assist nature 
in altering the presentation, by upward 
pressure on either the frontal or parietal part 
of the head, according as it may seem pos- 
sible to bring the vertex or the face down to 
become the presenting part. If seen early, 
the same manipulation recommended for the 
management of face cases may be suitable. 
If brow presentation persists, the forceps and 
even craniotomy may be required. 

Management of Difficult Occipito-pos- 
terior Cases when the Vertex Presents. 
— It being remembered that failure of the 
occiput to rotate anteriorly beneath the pubes 
is usually owing to incomplete flexion of the 
head, success will sometimes attend upward 
digital pressure on the sinciput continued 
for some time. Long, anterior rotation of the 
occiput may occur during descent of the head 
through the pelvis, or even when the perineum 
is reached, through the influence of the re- 
flected force of the latter. If the forceps is 
applied to the head in an occipito-posterior 
position, care should be taken that traction 
be sufficiently interrupted, occasionally, to 
ascertain if there be any tendency on the part 



142 MANUAL OF OBSTETRICS. 

of the head to rotate with the occiput for- 
ward. If such tendency be discovered, the 
forceps should be removed and re-applied, 
in order that the rotation may take place. 

Transverse Presentations.— "When the 
long diameter of the fetus crosses the axis of 
the uterus, there is produced a transverse, or, 
after the operation of uterine contractions, a 
shoulder presentation" (Lusk). Less fre- 
quently the arm, hand, side, back, or abdo- 
men may be the presenting part. Transverse 
presentations occur once in 230 labors. 

Varieties, four in number, are dor so-ante- 
rior, with fetal head to the right or to the left 
of the mother; and dorso-posterior with head 
to the right or to the left. The child lies 
with its back to the mother's abdomen with 
twice the frequency that it lies with its back 
toward the mother's spine. 

Causes. — Prematurity and death of child 
have an influence, for vital action of the child 
being feeble or absent, the fetus is less prone 
to take the usual position in utero to which 
it is best adapted. Excess of liquor amnii 
and flabby uterine or abdominal walls favor 
cross-births, because the child has greater 
opportunity to assume any unusual position. 
When the child is small and premature, there 



MANUAL OF OBSTETRICS. 143 

is always relatively an excess of liquor amnii. 
Deformity of the pelvic brim, placenta previa, 
or tumors which involve the cervical region, 
prevent the head from occupying the cervix, 
and tend to its displacement to one or the 
other iliac region, bringing the shoulder into 
the cervix. 

Uterine obliquity favors shoulder presenta- 
tion in the same way. Transverse or oblique 
position of the fetus will be met with not in- 
frequently in the latter part of pregnancy, 
which will be spontaneously corrected before 
labor occurs. 

Prognosis depends much upon the time in 
labor at which a case is seen, as the facility 
with which the child may be made to change 
its position to a natural one is much lessened 
with advanced labor attended by evacuation 
of liquor amnii and engagement or impaction 
of the shoulder. In cases seen late the mother 
is exposed to the constitutional and local 
dangers of protracted labor, as well as to the 
dangers of operative measures, which are not 
inconsiderable, and are often protracted. The 
mortality to the child is similarly increased f 
reaching in protracted cases 50 to 75 per cent. 

Diagnosis. — Suspicion may be excited early 
in labor by failure to perceive any presenting 



144 MANUAL OF OBSTETRICS. 

part per vaginam, and recognizing a rounded 
shape to the protruding bag of waters. Later 
the examining finger will appreciate beyond 
doubt the true condition. 

The abdomen may be rounded, or broad- 
ened with much diminished vertical length. 
The hard, rounded head may be distinguished 
elsewhere than in the supra-pubic region, 
while the breech may be distinguished at 
some lateral part of the uterus. The recog- 
nition of the hand, elbow, shoulder, ribs, or 
abdomen can be made when the os is half or 
three-fourths dilated, the differentiation be- 
tween the first mentioned parts and the foot, 
heel or breech having already been spoken of. 
It remains, however, to determine the exact 
position of the child. 

If the arm and hand can be examined, re- 
member that when the latter is supine, the 
palm is directed toward the child's abdomen, 
and the thumb toward its head. If the arm 
is in the uterus, in case either the shoulder or 
side presents, the axillary space can be recog- 
nized and is known to be directed toward the 
breech, while the scapula corresponds to the 
back of the child and the clavicle to the abdo- 
men. 

Natural termination, when the shoulder 



MANUAL OF OBSTETRICS. 145 

presents, takes place in exceptional cases only, 
and by one of two methods, viz., spontaneous 
version, or spontaneous expulsion. 

In the first instance — spontaneous version — 
during the pains the shoulder, which has 




Fig. 39.^Dorso-anterior position. 

been presenting, slips upward toward that 
iliac fossa previously occupied by the child's 
head, the head at the same time receding. 
As the shoulder slips up it leaves room for 
the side, hip and breech to descend, succes- 
sively to the cervical region, and labor termi- 
nates as in breech cases. Less frequently, 
a reversed order of events may substitute the 



146 



MANUAL OF OBSTETRICS. 



head for the side or shoulder, as the present- 
ing part. The phenomena of spontaneous 
version will be observed only when the pre- 
senting shoulder has not become firmly 
wedged into the pelvic inlet, mobility of the 
fetus bring essential, propulsion of the fetus 




Spontaneous expulsion. 



being favored by more vigorous contraction 
of one side of the uterus than of the other. 

Spontaneous expulsion occurs with small 
children who are either dead or feeble, few 
children surviving who are born by this mech- 
anism. The shoulder descends until it 
reaches the sub-pubic arch. Its farther de- 
scent being prevented by the head which over- 



MANUAL OF OBSTETRICS, 147 

laps the false pelvis, the presenting shoulder 
remains as a fixed point past which the trunk, 
breech, and lower extremities are crowded by 
the force of uterine contractions, the head be- 
ing the last part born. Dead children are 
those most liable to this method of delivery 
as they possess little resiliency of tissues. 

Treatment. — In all cases accurately deter- 
mine the position of the fetus; then, by what- 
ever way that will least involve interference 
with, or handling of the uterus, alter the pres- 
entation to that of vertex or breech. Previous 
to rupture of the membranes, external man- 
ipulation may accomplish version. If labor 
be farther advanced, and the shoulder fixed 
at the brim, combined external and internal 
manipulation, or, failing in this, internal ver- 
sion will be appropriate. If the child in its 
mal-presentation cannot be dislodged from 
the pelvis, embryulcia with, in some in- 
stances, decapitation will be required. 

MULTIPLE PREGNANCY. 

Twins occur once in eighty labors; triplets 
once in 7,000; quadruplets and quintuplets 
with great rarity, while the uterus has never 
contained more than five children in any one 
pregnancy. 



148 MANUAL OF OBSTETRICS. 

Twins may result from impregnation of a 
double-yelked ovum, or of two ova which 
may arise from rupture of one or more Graa- 
fian follicle. When developed from one 
ovum, with two centres for fetal growth, we 
have separate placentae (though they may be 
closely adjacent), and we have present in the 
septum between the amniotic cavities two 
membranes only, i. e. , the two amnions — the 
chorion and decidua being continuous directly 
from the surface of one amniotic sac to the 
other. When two ova are fertilized, each fe- 
tus will be entirely surrounded by both amnion 
and chorion, four membranes being present, 
therefore, in the septum between the chil- 
dren. When, as is rarely the case, the chil- 
dren are in a common cavity, it is probable 
that the septum has been destroyed by some 
accident. There is often an anastomosis of 
the vessels of the two placentae. 

Most frequently twins consist of a male 
and a female:— in instances of impregnation 
of a double-yelked ovum the children are al- 
ways of the same sex, as they may be, of 
course, when from two ova. A twin child 
is of less size and possessed of less constitu- 
tional vigor than one born singly, and it often 
happens that there will be a marked disparity 



MANUAL OF OBSTETRICS. 149 

in size and strength in twin children. Some- 
times one child loses its vitality and, though 
retained in utero until term, will then be 
found flattened and shrivelled. 

There is a well-marked element of hered- 
ity in the production of multiple pregnancy. 

Diagnosis of twin pregnancy can only be 
made with certain conviction when two fetal 
hearts can be heard with different rates of 
pulsation. The recognition of what appears 
to be the fetal parts of two children may ex- 
cite strong suspicion. Excessive size of the 
uterine tumor is an uncertain sign, as it could 
depend upon a very large child, or upon ex- 
cess of liquor amnii. 

Peculiarities of labor. — It is not rare to 
have premature birth. In most cases the di- 
latation of the cervix and descent of the first 
child requires more time than the average 
duration of normal labor. This is because 
the uterine force, being transmitted to the 
presenting child through the amniotic fluid 
and body of the other child, loses much of its 
strength, and also because over-distention 
interferes with efficient uterine action. 

After birth of the first child there is subsid- 
ence of pain for a period varying from half 
an hour to many hours. When pains again 



150 MANUAL OF OBSTETRICS. 

occur, however, the second child is expedi- 
tiously delivered. It is rare for the placenta 
of the first child to be expelled until both 
children have been born. 

Manner of presentation, as stated by Spie- 

gelberg, is as follows: 

Both heads presenting, . 49 per cent. 

Head and breech, . .31.7 

Both breech, . . . 8.6 

Head and transverse, . 6.18 

Breech and transverse, . 4.14 

Both transverse, . .0.35 

Locking twins may occur when the first 

child, having presented by the breech, has 

its body delivered. Then the head of the 

second child may descend slightly in advance 

of that of the first, and may be caught 

between the chin and thorax of the first 

child. Head locking may take place when 

both children present by the vertex, the head 

of the second child being held between the 

chin and thorax of the first child. Head 

locking is uncommon because the separate 

amniotic sacs prevent the heads from coming 

in close contact. 

Prognosis. — In twin cases one child in 
thirteen is still-born, danger to the child 
arising from prematurity, feebleness, malpre- 



MANUAL OF OBSTETRICS. 



151 



sentation, head locking, and operative mea- 
sures. The mother is exposed to the dangers 
of tedious labor, and to hcemorrhage, and 
septic poisoning, to which there is increased 




Fig. 41. 

facility, owing to the large area left bare 
after expulsion of placentae. 

Treatment. The placental end of the fu- 
nis of the first child should be ligated lest, 
if left to bleed, blood be abstracted from 



152 



MANUAL OF OBSTETRICS. 



the circulation of the second child. Traction 
on the funis of the first child should never be 
made. The uterus should be encouraged to 
contract after birth of the first child, and 
subsequent to the delivery of the children 
the uterus should be closely watched to pre- 
vent haemorrhage. If head locking occurs, 
endeavor to disentangle the heads. Failing 
in this effort, it may be necessary to sacrifice 
one child by decapitation, and, as the second 
child is that most likely to be saved in these 
cases, it is better to decapitate the child 
which is advancing, removing that part 
which presents. The second child can then 
be delivered safely and the remaining part of 
the child, which presented first, will be born 
last. 

Super-fetation, an occurrence regarded 
as impossible by some writers, is the impreg- 
nation and development of an ovum when 
the uterus already contains a developing 
fetus. To make this possible in any given 
case, there must be ovulation during preg- 
nancy. It is maintained by those who believe 
it a possible event, that until the end of the 
second month of gestation the ovum may not 
reach a size, or be so situated in the uterine 
cavity as to close both Fallopian tubes, and 



MANUAL OF OBSTETRICS. 



153 



that through one of them an opportunity is 
afforded for an ovule and spermatozoa to 
meet. Those who oppose this theory explain 
such cases as present two fetuses of appa- 
rently different stages of development, by 
calling to mind the possibility of pregnancy 
in a bi-lobed uterus, or of ordinary twin 




Fig. 42.— Showing the cavity between the decidua 
vera and the decidua reflexa during the early months 
of pregnancy. 

pregnancy with arrested development of one 
child. 

Super-fecundation is the impregnation of 
two ova at about the same time, by separate 
acts of coition, and before the formation of 
the decidua. 



154 MANUAL OF OBSTETRICS. 

Excessive Fetal Development is most 
apt to occur when one or both parents are of 
large size, and it is the large size of the child's 
head rather than its trunk which will occa- 
sion serious obstruction to delivery. It will 
be indicated by failure of the head to engage 
in the pelvio brim. When the forceps is 
used, the wide separation of its handles will 
at once suggest the condition present. 
Treatment should be the same as that em- 
ployed when disproportion between the head 
and pelvis is owing to the latter being of the 
equally contracted variety. 

Premature Ossification of the fetal head 
may be associated with excessive size of the 
fetus, or may exist independent of it. It is 
more apt to occur in first than in subsequent 
labors, and can be appreciated by the exam- 
ining finger. It permits of less than normal 
moulding of the head. If natural delivery 
does not occur, the forceps, or even perfora- 
tion with cephalotripsy , may be required. 
In women who possess the habit of having 
children with unyielding heads, the induction 
of labor should be performed two or three 
weeks before term, not only in the interest of 
the child, but as an operation far more safe to 



MANUAL OF OBSTETRICS. 155 

the mother than a difficult forceps operation, 
or craniotomy. 

Hydrocephalus, varying from an increase 
of intra-cranial contents by a few ounces 
only, to that which will give a circumference 
of the head equal to that of an adult, occurs 
occasionally and offers serious impediment to 
delivery. The cranial bones are thin and 
widely separated. 

Diagnosis can be based upon perception of 
the cranial bones, with intervening, fluctuat- 
ing areas, and recognition of the hairy scalp, 
proving the part touched to be the head. 
Differentiation is necessary between this con- 
dition and cystic tumors, spina bifida, un- 
ruptured membranes, and dead, macerated 
fetal tissues. The head failing to engage, and 
forceps, when applied, showing wide di- 
vergence of the handles, if the patient be 
anaesthetized and the hand introduced into 
the vagina, an accurate diagnosis will be 
readily obtained. When the breech presents, 
as is quite common, diagnosis is less easy and 
will be made only when— the head failing to 
descend — a careful examination of the case is 
made. 

Prognosis. — Delivery without operative aid 
is uncommon. Early recognition of the con- 



156 MANUAL OF OBSTETRICS. 

dition and appropriate treatment removes 
almost all the dangers to the mother which, 
otherwise, would be those of protracted labor 
and extensive lacerations of the cervix, vagina, 
and perineum. The child usually perishes dur- 
ing labor, or dies soon after. 

Treatment, whether the child presents by- 
head or breech, ij to puncture the head, and 
allow the fluid to escape. Delivery will then 
readily occur. 

Hydro-thorax and Hydro-peritoneum, 
when offering obstacle to delivery, should be 
treated by aspiration. 

Fetal Tumors, when of sufficient size to 
create dystocia, are usually partly cystic, and 
require similar treatment. Embryotomy may 
be required. 

Monsters present three principal varieties : 
1st, two children which are united either by 
thorax, abdomen, or some part of the spine ; 
2d, a monstrosity having two heads and com- 
mon trunk and lower extremities ; 3d, a 
monstrosity having a common head, with 
separated body, and double lower extremi- 
ties. Various modifications of these varieties 
are met with, as well as monsters without 
the heart (acardiacus), or without the brain 
(anencephalus). 



MANUAL OP OBSTETRICS. 157 

Prognosis to the mother is generally favor- 
able ; to the child very unfavorable. Mon- 
sters are apt to be born prematurely, and 
often perish before the occurrence of labor, 
thereby losing resiliency of tissues. This ex- 
plains, in part, the fact that, in fifty per cent 
of cases, unaided labor will effect delivery. 

In the first variety mentioned, one child 
will be wholly born before the other enters 
the pelvis. Then the second follows, present- 
ing in a way reverse to that of the first child. 

Dicephalous monsters are often born with- 
out difficulty. If the breech presents, one 
head descends in advance of the other. If a 
head presents, it is delivered followed by the 
body, the other head being expelled last. 

When, as sometimes happens, impaction of 
the monster takes place, embryotomy will be 
necessary. 

Multiple Presentations may complicate 
labor, as when we have the hand and foot 
presenting together, or an extremity with the 
head. Efforts by conjoined manipulation, or 
by internal version, will usually successfully 
arrange the fetus in a way to secure delivery. 

Dorsal Displacement of the Arm.— In 
rare cases, either of head or breech presenta- 
tion, one arm may be thrown backward, so 



158 MANUAL OF OBSTETRICS. 

that the forearm may lie across the hollow of 
the neck. This circumstance produces a con- 
dition which may offer serious impediment to 
labor, producing arrest of descent, at a time 
when least expected. A careful examination, 
such as should be instituted whenever pro- 
gress is arrested in the course of labor, will 
make clear the nature of the obstaccle, less 
readily, however, when the head presents 
than in breech cases. Liberation of the arm 
will not be difficult if the child's body be car- 
ried backward to make room for the finger of 
the operator between the pubes and the 
child's neck. 

Tough Membranes which fail to rupture 
when the os is nearly dilated, occasion delay, 
chiefly because good expulsive pains are not 
prone to occur until after the discharge of 
liquor amnii. Treatment should be their 
rupture by the finger-nail, or by whatever 
may be conveniently at hand. Be careful 
that the discharge of water be not sudden, 
through a large rent, lest the funis be carried 
out in advance of the presenting part. 

Dry Labor — by which is meant labor at- 
tended by escape of liquor amnii before the 
os has attained much, if any, dilatation — is 
prolonged during the first stage, owing to 



MANUAL OF OBSTETRICS. 159 

the absence of the dilating hydrostatic wedge 
which is the chief factor in dilatation. 

The second stage may then be prolonged, 
owing to the establishment of partial uterine 
inertia from the protraction of the first stage. 
Owing to the prolonged close application of 
the uterus to the fetus, the life of the latter is 
sometimes endangered from disturbed utero- 
placental circulation. Treatment should con- 
sist of the use of such remedies or methods as 
will accomplish cervical dilatation (see rigid 
os), while, at the same time, needed rest and 
support must be obtained for the patient. 

Long or short funis. Length of funis 
may complicate labor by permitting of its 
prolapse, a condition which will receive con- 
sideration on another page. The funis, by be- 
ing shorter than normal or, though long, by 
being coiled around the neck or body until 
practically shortened thereby, may create 
mechanical impediment to delivery, as well as 
danger to the child from disruption between 
placenta and uterus, or from undue tension of 
the cord during descent of the child. If the pla- 
centa does not yield to the traction occasioned 
by a short cord, partial inversion of the uterus 
may ensue. The funis has been known to be 
as short as two or three inches. Happily, 
instances of dangerously short cord are rare. 



CHAPTER VIII. 

ACCIDENTAL HEMORRHAGE. — PLACENTA PRE- 
VIA. — POST-PARTUM HEMORRHAGE. — SECON- 
DARY HEMORRHAGE. 

Accidental Hemorrhage. 

This is an escape of blood from the utero- 
placental circulation, caused by partial sepa- 
ration of a normally situated placenta from 
its attachments. 

Varieties of this form of haemorrhage exist, 
differing in gravity and in the group of 
symptoms. Blood may be effused in small 
amount and, by dissecting its way between 
the membranes and uterus, appear in the 
vagina, and the existence of the haemorrhage 
be then apparent. Another variety, known 
as concealed, internal haemorrhage, may pre- 
sent very serious symptoms. In this form, 
a large quantity of blood accumulates within 
the uterus, little or none appearing exter- 
nally. 



MANUAL OF OBSTETRICS. 161 

Haemorrhage of the kind described receives 
its distinctive title, "accidental," when it 
occurs during the last three months of preg- 
nancy. Occurring early in pregnancy, we 
have simply that condition which is common 
in abortion, and the small size of the uterus 
prevents any alarming internal accumulation 
of blood. 

Causes immediately producing the haemor- 
rhage are irregular contractions of the uterus 
which disturb the relations of uterine and 
placental surfaces, or sudden determination 
of blood to the uterus and placenta. Trau- 
matism or emotion may provoke these con- 
ditions, and — as predisposing to them — we 
have degenerations of the placenta and such 
constitutional states as anosmia, syphilis, or 
blood-poisoning from any source. 

Diagnosis. When not of the concealed 
variety, diagnosis is not difficult, it being of 
primary importance in these cases to deter- 
mine that placenta previa does not exist, and 
this can be determined by digital examination 
of the cervix, which will determine the pres- 
ence or absence of the placenta at the cervi- 
cal orifice. 

In concealed haemorrhage the amount of 
blood extravasated may be very great. The 



162 MANUAL OF OBSTETRICS. 

situation of the placenta in this condition is 
likely to be in the upper half of the uterus, 
and the first extravasation most commonly 
occurs near the middle of the placenta. 
Hemorrhage continuing, the effusion takes 
that direction in which there is least resist- 
ance. If it proceeds in any direction except 
downward toward the cervix, an enormous 
amount may be lost from the general circu- 
lation without any external loss. When the 
extravasation is confined by the adherent 
margin of the placenta, or by the membranes, 
distention and bulging of the uterus are pro- 
duced, and even rupture. 

Pain is wholly different from that of natu- 
ral labor. It is cramp-like and constant, and 
conveys to the patient the idea of extreme 
tension. It is most severe and agonizing, 
and is chiefly confined to a circumscribed 
part of the abdomen. It is an early symp- 
tom, but soon there are associated with it 
symptoms which indicate collapse. 

The state of collapse arises in part from 
loss of blood and in part from shock to the 
nervous system. It is indicated by the feeble 
and quickened pulse, pallor and a pinched 
expression of countenance, coldness of the 



MANUAL OF OBSTETRICS. 163 

surface of the body, shallow respiration, rest- 
lessness, and retching. 

It will be noted that labor pains are absent 
or feeble in character. Palpation, under the 
favoring circumstances of a thin and relaxed 
abdominal wall, will show in extreme cases 
distention and irregularity of uterine contour. 

Opposite the extravasation an accessory 
tumor may be present, caused by a bulging 
of the uterine wall. Not infrequently a dis- 
charge of blood or of serous fluid will appear 
after these symptoms have persisted some 
time. Serous discharge from the vagina is 
not the escape of amniotic fluid, but is the 
watery element of the coagula, which by 
their compression is forced out. 

The rupture of the membranes near the 
seat of the effusion, and the consequent 
appearance of blood in the liquor amnii, 
holds, as a symptom, the lowest rank in the 
order of frequency (Goodell), because, should 
the os uteri be closed, the membranes, how- 
ever delicate, cannot, other things being 
equal, rupture any sooner than the uterine 
walls, for the sum of resistance of the inclosed 
liquor amnii, being equally distributed, ex- 
actly counterbalances the sum of the pressure 
exerted by the effusion. 



164 MANUAL OP OBSTETRICS. 

An examination of the uterine contents 
expelled after the birth of the child reveals 
the placenta flattened or hollowed on its ma- 
ternal surface, and a large amount of coagu- 
lated blood of varying color and consistence, 
some being partially decolorized and quite 
firm. 

At the onset of the symptoms the condition 
of intestinal colic would most resemble that 
of concealed haemorrhage. A careful exami- 
nation of the pregnant uterus, and the 
occurrence of the more severe symptoms, 
especially those of loss of blood, would be 
the means for determining between the two 
conditions. 

When the symptoms of collapse are pres- 
ent, the accident might be mistaken for 
rupture of the uterus. The history of the 
case would help us to a diagnosis, in that the 
former condition occurs prior to or early in 
labor, while the latter takes place at a later 
stage. Uterine rupture is attended by retro- 
cession of the presenting part and diminution 
in the size of the uterus when the fetus has 
wholly or in part escaped from that organ, 
and the membranes are relaxed or more 
commonly ruptured. Concealed haemorrhage 



MANUAL OF OBSTETRICS. 165 

causes increased size of the uterus, and the 
membranes are usually entire. 

Prognosis in cases of concealed haemor- 
rhage is that fifty per cent of mothers and 
nearly all children perish. 

Treatment demands exercise of great judg- 
ment. In the variety of accidental haemor- 
rhage attended by the escape of blood from 
the os, without the occurrence of symptoms 
of shock, the labor is likely to set in sponta- 
neously and the case terminate favorably — or 
the haemorrhage may cease, and pregnancy 
continue to its natural termination. If in 
these cases we find the constitutional signs of 
haemorrhage persisting, even in slight degree, 
close attention must be given with a view to 
assisting in delivery before alarming symp- 
toms occur. 

The safety of the child is endangered, not 
only in case of its premature expulsion, but 
also by loss of blood and injury to the utero- 
placental circulation. In the grave cases of 
accidental haemorrhage there is no safety 
until after delivery. It must be brought 
about speedily, while every measure is taken 
to diminish the haemorrhage which will be 
continuing in greater or less degree. No 
means should be overlooked to rally the wo- 



166 MANUAL OF OBSTETRICS. 

man from the effects of shock and haemor- 
rhage. Dilatation of the os must be brought 
about, or aided, by artificial means, Barnes* 
dilators being most suitable. Preserve the 
membranes unruptured until cervical dilata- 
tion is obtained, thus tamponing the uterine 
cavity with liquor amnii. 

When the os is dilated version meets the 
indications better than the forceps, as by the 
former operation there is less danger from 
delay during delivery, and because it can be 
successfully resorted to at an earlier period 
in dilatation than can the forceps. Bimanual 
version should not be considered, as in this 
accident the irregularity of the internal ute- 
rine surface caused by the collection of blood 
would certainly interfere with the change of 
position of the child. 

During the entire time stimulants must be 
freely used and warmth to the surface, and 
in exceptional cases, when the haemorrhage 
does not appear to be continuing, it is proper 
to wait for returning vitality bet ore operative 
measures are undertaken, lest the condition 
of collapse be aggravated. 

The danger is not necessarily over after de- 
livery, for it is often difficult to bring about 



MANUAL OF OBSTETRICS. 167 

reaction from the dangerous condition, and 
convalescence will often be slow. 

Placenta previa, unavoidable haemor- 
rhage, occurring once in 570 labors, is an im- 
plantation of the placenta so that it wholly 
or partly covers the internal os. If the cer- 
vical opening is entirely covered by the pla- 
centa, the condition is termed placenta 
centralis, or complete placenta previa. Ac- 
cording as the cervical opening is partly 
covered by, or has its margin in close prox- 
imity to the placenta, we use the terms pla- 
centa partialis, or marqinalis. If the placenta 
is within two or three inches of the closed 
cervix, we are liable to unavoidable haem- 
orrhage at labor. 

Causes are not clear, yet we find the con- 
dition most commonly in women who have 
borne children and have large, relaxed uteri 
with enlarged cavities. 

Clinical history. Doubtless many cases 
go unrecognized, as abortion is a frequent 
event when the placenta is previa and will 
occur often when its cause has not been dis- 
covered. In such cases as come under ob- 
stetric consideration, we find one or more 
haemorrhages taking place at any time during 
the last four months of pregnancy, most 



168 MANUAL OF OBSTETRICS. 

commonly during the seventh and eighth 
months. The developmental changes in the 
cervix and lower uterine segment are the 
cause for these haemorrhages, which may, 
however, be deferred until the occurrence of 
the changes in the cervix of the preparatory, 
or first stage of labor. Haemorrhage may 
immediately depend upon some exertion, or 
may come on when the body is at perfect rest 
owing to some unusually vigorous uterine 
contraction, it being remembered that ryth- 
mical uterine action takes place during the 
whole of pregnancy. The source of blood is 
some utero-placental sinus which is ruptured 
by slight separation of the placenta from the 
uterus, and as there is but slight disposition 
to contract on the part of the soft tissues of 
the cervix, and as there is nothing to check 
haemorrhage except the formation of coagula, 
or lessened force of the circulation, we find 
the amount of blood to be considerable. The 
haemorrhages are generally sudden and pain- 
less, quickly filling the vagina with clots. 

One haemorrhage is usually followed by 
another within a short time, which is due to 
further separation of the placenta from its 
attachment. The loss of blood may be fatal 
when but two or three attacks have occurred, 



MANUAL OF OBSTETRICS. 169 

the most copious haemorrhages being likely 
to occur in the beginning of labor. Malpres- 
entations are common, partly owing to the 
frequency of premature labor and partly 
because the presence of the placenta in the 
lower zone of the uterus is apt to displace the 
head of the child. Unless precautions are 
taken to prevent haemorrhage, the patient be- 
comes weak, with all the constitutional signs 
of loss of blood. 

Prognosis is grave. Statistics show mortal- 
ity to mother of 25 to 33 per cent, while 50 to 
75 per cent of children perish. Mothers die 
from exsanguination, exhaustion, and septi- 
caemia, to which there is liability owing to 
lowness of placental site and the consequent 
facility with which thrombi can become de- 
tached and germs can be brought to it. It is 
not uncommon for patients who receive in- 
sufficient care to die undelivered. Appropri- 
ate treatment will much reduce the mortal- 
ity. 

Diagnosis. The sudden, profuse, and pain- 
less character of the haemorrhage should 
always arouse a strong suspicion that pla- 
centa previa exists, while any discharge of 
blood in the latter part of pregnancy should 
lead the medical attendant to employ reason- 



170 MANUAL OF OBSTETRICS. 

able means to clear up the diagnosis. During 
labor each uterine contraction extends 
slightly the separation of the placenta, and 
immediately following the contraction there 
is a renewal of the haemorrhage. The dis- 
charge of blood during the pain is simply an 
expulsion of blood already effused, the first 
effect of the pain being to constrict vessels 
even though placental separation is increased, 
actual bleeding taking place in the intervals 
of contractions. 

Vaginal examination when the placenta is 
previa shows a cervix longer and softer than 
normal, owing to unusual development caused 
by increased afflux of blood to the part. The 
external os is quite patulous. When haem- 
orrhage has just occurred, a recent clot 
will be present, usually, in the cervix. This 
must not be mistaken for the placenta, the 
latter being distinguished by its fleshy 
and fibrous character, and, unless parti- 
ally detached and hanging in the cervix, 
the placenta will be situated at a higher 
level than the coagulum. If the placenta 
be central, the presenting part of the 
child will not be appreciated through the va- 
ginal part of the uterus. If the placental at- 
tachment be marginal, that part of the uterus 



MANUAL OP OBSTETRICS. 171 

which is covered by placenta has a thickened 
boggy feel, and the presenting part will be 
distinguished at the opposite side of the cer- 
vix. The location of the uterine bruit is 
valueless as an aid to diagnosis. In a case of 
central placenta previa I have been able to 
hear it above the level of the umbilicus only. 

Treatment.— Induction of premature labor 
should be performed at any time after viabil- 
ity, when we have had clear indications of 
the existence of placenta previa. It may be 
wise in some cases to resort, in the interest of 
the mother, to this treatment before viability 
of the child even. When the fetus has 
reached an age at which it is capable of sus- 
taining extra-uterine existence, induction of 
labor provides for its safety as well, for when 
depending for life Upon a torn and bleeding 
placenta, its chances for survival are small. 

The best way to induce labor is by the use 
of the Barnes dilators, which accomplish, in 
a brief time, the double purpose of cervical 
dilatation and direct tamponing of the bleed- 
ing surfaces. 

If there be a desire to temporize, a, properly 
applied vaginal tampon may control haemor- 
rhage for the time being. 

When called to a case of placenta previa in 



172 MANUAL OF OBSTETRICS. 

which the first stage is near, or at completion, 
obstetrical interference should be such as 
will most speedily remove the child, while at 
the same time haemorrhage be controlled. 

If the child is alive, internal podalic version 
will best meet the indications in the great 
majority of cases. Rupture of the membraes 
should be relied upon only when the uterine 
contractions are strong and the placenta has 
marginal attachment. Forceps may be used 
in the same class of cases, if the uterus fails 
to cause descent of the head. Delivery by 
forceps requires considerable time, as the cer- 
vix is apt to be long and not widely dilated. 
The introduction of the blades may be diffi- 
cult, and even harmful by causing further 
detachment of the placenta. 

Partial separation of the placenta through- 
out the entire periphery of the cervix (Barnes* 
method), or the complete separation and re- 
moval of the placenta in advance of the child 
(Simpson's method), are measures proper 
when the child is dead or not viable, or when 
version would be unwise or difficult. 

The conditions which render these methods 
superior to version are, 1st, a uterus firmly 
contracted, with entire escape of liquor am- 
nii; 2d, a pelvis so contracted as to make 



MANUAL OF OBSTETRICS, 173 

turning and extraction of the child difficult; 
3d, a patient so prostrated as to be unable to 
bear the operation of version. 

POST-PARTUM HEMORRHAGE. 

This may occur either before or after deliv- 
ery of the placenta, may be slight or severe, 
and will be met with rarely or frequently ac- 
cording as proper or imperfect attention is 
bestowed upon lying-in cases. Causes are de- 
ficient, or irregular uterine contraction, and 
lacerations in the parturient canal. 

Deficient uterine action, or inertia uteri, 
permits the mouths of the veins of the uterus, 
laid bare by separation of the placenta, to re- 
main open to pour out blood which may es- 
cape into the vagina, or which may be ob- 
tained by the obstructing presence, in the 
cervix, of a clot or placental fragment — in the 
latter case constituting concealed hcemor- 
rhage. If the uterus contracts irregularly, 
the absence of valves in the uterine veins 
favors haemorrhage. 

Uterine inertia may be produced by the ex- 
haustion of successive pregnancies, life in 
tropical climates, prolonged labor, over-disten- 
tion as from twins or excess of liquor amnii, 
or by a debilitated constitutional state. The 



174 



MANUAL OF OBSTETRICS. 



completion of precipitate labor or of labor 
hastened by forceps or version does not find a 
uterus which has been gradually roused to 
the perfection of its function of contraction, 
and in these cases we are liable to meet with 
abnormal relaxation. 

Irregular uterine action, as when certain 
bands of muscular fibres contract while others 
do not, may be a functional disorder, may be 




Fig. 43.— Irregular contraction of the uterus. 

due to uneven development of the muscular 
walls of the uterus, may arise from retention 
of placenta or clots, or be excited by misman- 
agement of the third stage of labor, as when 
it is attempted to deliver the placenta by trac- 
tion upon the coid alone. 



MANUAL OF OBSTETRICS. 175 

Placental adhesion — not often met with, 
and for which placental retention is some- 
times mistaken — may exist throughout the 
whole or a part of the surface of the placenta. 
A part or the whole of the placenta is liable 
to be retained and, preventing contraction of 
the uterus, haemorrhage ensues. 

Symptoms. — To the attendant, with hand 
upon the uterus, it becomes evident, very 
soon, if there is a disposition to haemorrhage. 
If the uterus relaxes, its fundus rising, and is 
with difficulty made to contract, close atten- 
tion should be given to the vaginal discharge. 
This may be found considerable in amount, 
with or without coagula, though there may 
be absence of haemorrhagic vaginal discharge 
while the uterus and vagina are filled with 
coagula. A suspicion of the existence of in- 
ternal haemorrhage will be confirmed if on 
examination the vagina and cervix are found 
to contain clots. The earliest constitutional 
sign is a quickened and weakened pulse. 
Speedily following, in the severe cases, are 
pallor, cold perspiration, a sensation as if 
more air was needed, dizziness, restlessness, 
partial or complete syncope. 

Preventive treatment. — The natural way in 
which abnormal loss of blood is prevented is 



176 MANUAL OF OBSTETRICS. 

by complete emptying of the uterus of clots 
and secundines, permitting contraction of its 
muscular fibres, some of which, interlacing, 
and surrounding the open vessels of the pla- 
cental site, prevent the escape of blood to any 
amount. The small amount of blood remain- 
ing in the slightly open orifices, coagulates 
and plugs them up. In the management of 
labor much can be done to prevent haemor- 
rhage, by promoting this normal uterine ac- 
tion. To do this, keep the hand continuously 
upon the uterus from the birth of the child 
for half an hour or as much longer as is neces- 
sary to secure tonic, uterine contraction. If 
the uterus is disposed to relax, gentle, down- 
ward and lateral pressure with manipulation 
is stimulating to it. Do not apply the binder 
until permanent, tonic uterine contraction is 
obtained. Its presence interferes with neces- 
sary observation and treatment of the uterus. 
If there be manifest tendency to relaxed 
uterus, examine with the finger in order to 
detect and remove coagula from the cervix. 
Give a full dose of ergot when the child i3 
born. It is probable that the delivery of the 
placenta within five minutes after the birth 
of the child insures better uterine contraction 



MANUAL OF OBSTETRICS. 177 

than when the uterus is partly distended by 
it for fifteen or more minutes. 

Treatment when hcemorrhage is present, — 
Empty the uterus of all which it contains, by 
the introduction of as much of the hand as is 
necessary. At the same time grasp the 
uterus, through the abdomen, with the other 
hand, and compel it to descend and contract. 
Maintain its contraction by manipulation and 
downward pressure, adding, if necessary, the 
stimulus of the other hand, of ice, or of hot 
water within its cavity. This method of 
treatment, if intelligently and persistently 
kept up, will rarely fail to accomplish the 
desired result. Other useful means are cold 
to the abdomen, and flaggellation with damp 
towels. Empty the bladder if found dis- 
tended. To the uterine cavity we may apply 
a continuous stream of hot water (110° F.), 
vinegar or iodine by sponge or injection, and 
sol. Jerri subsulph., the latter only when all 
other means fail. Hypodermic injections of 
ergot, and the Faradic current, one pole at 
the cervix the other on the abdomen, will be 
of great use. 

When the placenta has not been expelled, it 
should be promptly removed, but with care 
that no part of it or of the membranes be left 



178 MANUAL OF OBSTETRICS. 

behind. When adherent, the fingers should 
be gently insinuated between placenta and 
uterus until removal en masse can take place. 
If, as rarely happens, small portions of the pla- 
centa are so firmly adherent that they are, of 
necessity, left behind, prolonged watchfulness 
against haemorrhage will be necessary, with 
frequently repeated antiseptic, intra-uterine 
douches for days subsequent to labor. During 
all local treatment, be careful to avoid increas- 
ing the already present condition of exhaus- 
tion. To restore vitality, apply warmth to the 
extremities, adminster stimulants, hypodermi- 
cally at first; later, when absorption by the 
stomach can take place, by that organ. To 
prevent cerebral anaemia, lower the head of 
the patient and elevate the foot of the bed. 
Compression of the aorta and bandaging the 
extremities promote the same purpose. 
Transfusion of blood or milk will be proper 
in extreme cases. 

Lacerations of maternal structures, usually 
of cervix or perineum, may produce haemor- 
rhage which wdll be distinguished from the 
other variety by observing that the uterus is 
not distended or relaxed. Pressure, local ap- 
plication of styptics, or bringing torn surfaces 



MANUAL OF OBSTETRICS. 179 

into apposition by sutures will overcome the 
haemorrhage. 

Secondary post-partum haemorrhage, 
occurring later than twenty-four hours after 
labor, as a grave condition is rare. In lesser 
degrees it may arise from lacerations and con- 
tusions of soft parts, or dislodgment of 
thrombi from uterine sinuses which may take 
place at a time when small retained coagula 
are expelled by post-partum contraction of 
the uterus. In serious form it will be found 
associated with separation of an extensive 
slough, or with septic endometritis. It 
should be treated by the methods already 
mentioned, it being permissible in selected 
cases to employ the vaginal tampon. 



CHAPTER IX. 

PROLAPSE OF THE FUNIS.— INVERSION OF THE 
UTERUS.— RUPTURE OF THE UTERUS. — LACE- 
RATIONS OF THE CERVIX, VAGINA, AND PE- 
RINEUM. — RUPTURE OF PELVIC JOINTS. — 
PUERPERAL ECLAMPSIA. — THROMBOSIS AND 
EMBOLISM. — PUERPERAL INSANITY. 

Prolapse of the funis occurs once in two 
hundred cases of labor, and consists in de- 
scent of a part of the cord in advance of the 
presenting part of the child, either before or 
after rupture of the membranes. If the 
membranes have ruptured, while the head is 
still at the brim, the cord may present at the 
vulva, coming down laterally or posteriorly. 

Causes are excessive length of funis, low im- 
plantation of the placenta, such conditions as 
make easy the recession of the presenting 
part from the lower uterine segment, as 
hydramnios and twin pregnancy, and such 
conditions as prevent the presenting part 



MANUAL OF OBSTETRICS. 181 

from accurately filling the pelvic brim, as 
deformity of the pelvis and breech and shoul- 
der presentations. 

Prognosis. — The only danger to the mother 
arises from operative treatment which may 
be necessitated. The mortality to the child 
is more than fifty per cent, the co-existence 
of head presentations causing greater danger 
than those of shoulder or breech. 

Diagnosis is generally easy. If the loop of 
funis is felt in the vagina, or seen, no error 
can arise. Early in labor, when the os is 
partly dilated and membranes unruptured, 
the presence or absence of funis presen- 
tation can be ascertained unless examina- 
tion is hasty and incomplete, and the 
importance of early recognition of the com- 
plication cannot be too much emphasized. 
The funis appears to the finger as a movable, 
compressible body, unlike any thing else which 
is encountered in this situation; pulsation, 
if present, facilitating diagnosis. Diagnosis 
is not complete until it be ascertained whether 
or not the child is dead. The fetal heart 
should be listened for, and if not heard and 
the funis be not pulsating, it will still be neces- 
sary to prolong examination, for during 
uterine contractions the circulation in the 



183 MANUAL OF OBSTETRICS. 

cord may be so much obstructed and so feeble 
that pulsation cannot be detected, yet fol- 
lowing the pains, circulation may be re-estab- 
lished and pulsation be restored. If exami- 
nation be first made in the interval between 
pains it should be resumed when the succeed- 
ing pain occurs in order to ascertain whether 
danger is threatened. When still-birth takes 
place, it is due to interruption of the circula- 
tion of the funis from its compression be- 
tween the pelvic wall and the child during the 
latter's descent. 

Treatment. — If a case be seen early, carefully 
guard against rupture of the membranes by 
keeping patient in bed. As long as the cir- 
culation of the funis is not impeded, there is 
no imminent danger, and no interference is 
necessary, though postural treatment is 
proper and often useful at this time. Place 
the patient on her chest and knees and let her 
retain this position during several pains, at 
the same time gently displace the funis from 
the centre to the margin of the cervix. Grav- 
ity will often cause the prolapsed portion of the 
cord to seek a place toward the fundus uteri. 
If the method succeeds, it will be necessary 
to closely watch the case, for prolapse is 
prone to recur. If the membranes have rup- 



MANUAL OF OBSTETRICS. 183 

tured when the case is first seen, and the cord 
still pulsates, the same treatment should be 
employed. In all cases when the child is 
dead, no obstetrical aid is needed. 

Instruments have been devised for the pur- 
pose of conveying the cord into the uterus 
above the head, and one can be extemporized 
by passing a tape about the funis and attach- 
ing it to the eyelet of an elastic catheter. 
Such devices will rarely accomplish more 
that can be gained by the postural treatment. 
In using them, place the patient on chest and 
knees, or on the side opposite that at which 
the funis is prolapsed. If the cord cannot 
be returned, or, if returned, cannot be kept 
in the uterus, a selection must be made of 
the way best suited to each case, by which 
delivery can be accomplished with but brief 
compression of the cord. If the patient is a 
multipara, has roomy pelvis, the pains are 
strong and the head disposed to enter the 
pelvis, promote all natural efforts of labor, or 
use the forceps. If the patient is a primi- 
para and has opposite conditions to those 
mentioned, employ version. Always place 
the funis, during the passage of the head, in 
that part of the pelvis in which it would sus- 
tain least pressure, and accomplish rapid de- 



184 MANUAL OF OBSTETRICS. 

livery of the head. Obstruction of the circu- 
lation for more than two or three minutes 
will usually be fatal. 

Inversion op the Uterus, a partial or 
complete turning of the uterus inside out, is 
a very rare event, occurring once in many 
thousand cases of labor. The inversion may 
commence at the fundus, or at the cervix. 

Causes are spontaneous, irregular contrac- 
tion, parts of the uterus vigorously contract- 
ing while other parts are relaxed; traction on 
the funis, and improperly applied pressure 
from above. The accident is most likely to 
occur when there has been previous over-dis- 
tention of the uterus, or after hcemorrhage. 
The exciting cause may be violent straining 
efforts. When inversion commences from 
above, the depressed fundus, acting as a 
foreign body in the uterine cavity, stimulates 
active contraction until it is still further de- 
pressed and finally extruded. If inversion 
begins at the relaxed cervix, vigorous con- 
traction of the body and fundus will accom- 
plish the same result. If the placenta be 
closely adherent to a uterus disposed to irreg- 
ular contraction, undue traction on the funis 
by the attendant, or by the fetus if the cord 
is short, aids in producing inversion. 



MANUAL OF OBSTETRICS. 185 

Diagnosis. — In the beginning of the pro- 
cess it will be observed that the uterine bulk 
above the symphysis is less than usual, and a 
cup-shaped depression of the fundus is some- 
times observed. In the greater degress of the 
accident, little or none of the uterus can be 
appreciated by supra-pubic examination. 
Vaginal examination shows the presence of 
the inverted fundus. Co-incident with the 
local signs are symptoms of shock, often 
reaching an alarming degree, and, if there is 
a generally relaxed state of the uterus, haem- 
orrhage is present. An extruded polypus 
will not be mistaken for inversio uteri if at- 
tention is paid to the local condition, especi- 
ally if a sound can be made to pass above the 
former into the uterine cavity. 

Prognosis is serious in proportion to the 
time in which the condition goes unrecog- 
nized, or without successful treatment, 
though spontaneous reduction sometimes oc- 
curs. Fatal termination is not rare. 

Treatment. — Restore the uterus to its nor- 
mal condition as speedily as possible. Delay 
increases the difficnlty which attends reduc- 
tion, and aggravates the state of collapse. 
Steady the uterus with one hand above the 
pubes, while with the thumb and fingers of 



186 MANUAL OF OBSTETRICS. 

the other hand grasp and compress the in- 
verted fundus and guide it upward in the 
axis of the pelvis, with evenly applied force. 
In some cases pressure applied to the region 
of one Fallopian tube is more useful. When, 
the placenta is still adherent, it is probably 
better to remove it before reposition of the 
uterus, though by some it is advised to return 
the placenta with the fundus, thus avoiding 
possible haemorrhage. Anaesthetics may be 
necessary. Watch the case closely after re- 
duction, promoting uterine contraction lest 
inversion recur. The importance of using 
every means for overcoming shock, is great, 
for collapse is the cause of death in many 
cases. When the condition of inversion is 
overlooked, it may be remedied sometimes, at 
a period remote from its occurrence, by pro- 
longed pressure on the fundus by means of 
distended rubber bags kept in the vagina. 

RUPTURE OF THE UTERUS. 

This accident occurs once in 4,000 cases of 
labor, and generally begins in the lower ute- 
rine segment, extending upward toward but 
rarely to the fundus. The rent is sometimes 
oblique, commonly irregular, and rarely 
transverse. It is called complete when it 






MANUAL OF OBSTETRICS. 187 

connects the uterine with the peritoneal 
cavity, incomplete when limited to the mus- 
cular or peritoneal envelope. 

Causes. — Predisposing to the accident, in 
the large majority of cases, is localized degen- 
eration of the uterine parietes. Most fre- 
quently this is a fatty change, but may de- 
pend upon malignant infiltration, or presence 
of fibromata. In consequence, we note that 
women who have borne many children and 
are advanced in life are most liable. The 
fact that rupture most commonly begins in 
the lower uterine segment has been correctly 
associated with the thinning of that part of 
the uterine ivall consequent upon labor pro- 
longed in the second stage. When uterine 
contractions have continued for some 
time after cervical dilatation, the mus- 
cular fibres become attenuated — the same 
contractions driving the child forcibly 
against the uterine wall, which has be- 
come little more than membranous. Another 
cause for rupture of the uterus is pelvic de- 
formity, as when abnormal, bony promi- 
nences, from long contact with the uterine 
wall during labor, cause softening and lacera- 
tion. Cicatrices in the uterus, and all condi- 
tions, such as malpresentations, hydrocepha- 



188 MANUAL OF OBSTETRICS. 

lus, or deformed pelvis which cause delay in 
labor, favor the accident. 

Symptoms. — In the course of labor there 
will occur, suddenly, indications of shock and 
haemorrhage, i. e., rapid and feeble pulse, 
pallor, cold skin, vomiting, and syncope. 
Labor pains cease, to be instantly followed in 
many cases by very severe, constant pain, 
with sensation as if something had given way. 
A vaginal discharge of blood takes place. 

Physical signs vary according to the extent 
to which the child passes into the abdominal 
cavity. In a characteristic case, there will be 
recession of the presenting part, perception of 
the fetus readily mapped out through the ab- 
dominal wall, and presence of the globular 
uterus, reduced in bulk, at one side of the 
abdomen. Intestine has been known to ap- 
pear in the vagina, and in rare cases, emphy- 
sema of the cellular tissue of the abdomen. 
Incomplete rupture affords no typical signs, 
rapid pulse being of chief prominence, with 
diminished and disordered uterine action. 

Prognosis. — Mortality to mother is 85 per 
cent, while children almost inevitably perish. 
Danger to mother arises from collapse, haem- 
orrhage, peritonitis, and septicaemia. 

Treatment. — Prophylaxis consists in always 



MANUAL OF OBSTETRICS. 189 

guarding against dangerous delay in the sec- 
ond stage of labor. After rupture of the 
uterus, the indications are for removal of 
child by such means as will lessen the dangers 
which threaten the mother. 

If the fetus is entirely or chiefly in the 
uterus, it may be removed by the natural out- 
let either by forceps or version. The latter 
operation should be performed by delicate 
manipulation only, the uterus being steadied 
by a skilled assistant. In vertex cases, per- 
f orate rather than make prolonged efforts 
with the forceps, and during perforation 
steady the head with the forceps. The pla- 
centa must be removed by the hand, and, if 
it has escaped into the abdominal cavity, gen- 
tle traction on the cord will bring it within 
reach. Before leaving the case, make sure 
that no intestine is in the uterus and liable to 
strangulation. When the whole or a consid- 
erable part of the child has entered the peri- 
toneal cavity, laparotomy should be per- 
formed, not because the child can be removed 
most easily by this method, but in order that 
the removal of all irritating material from 
contact with the peritoneum can be accom- 
plished. A large number of obstetricians be- 
lieve that all cases of complete rupture should 



190 MANUAL OF OBSTETRICS. 

be thus treated. By no other means can 
blood, liquor amnii, and vernix caseosa be 
removed, while the operation permits also of 
the application of sutures to the uterus, 
which may control haemorrhage. Efforts to 
restore the patient from collapse must be en- 
ergetic. 

Lacerations of the cervix are of com- 
mon occurrence, and are serious chiefly from 
the fact that, failing to heal, they prevent 
normal involution and lay the foundation for 
many uterine disorders. They are caused by 
forcible stretching of the cervix by passage 
of the head, by the finger of the attendant, 
or by forceps. (Edema of the cervix favors 
the accident. These lacerations usually cor- 
respond in direction to the axis of the parturi- 
ent canal, though transverse and annular tears 
may rarely occur. It is a significant fact that 
during late years, in which the forceps is used 
often and early, we find laceration of the cer- 
vix prominently occupying the attention of 
gynecologists instead of vesico- and recto- 
vaginal fistulas, which we know to arise from 
too infrequent use of the instrument. Im- 
mediate closure with sutures is not regarded 
as an easy or desirable operation. 

Lacerations of the vagina are usually 



MANUAL OF OBSTETRICS. 191 

associated with pelvic deformity, or with 
lacerations beginning in the uterus. In cases 
in which they occur, operative treatment is 
usually inappropriate lest it prolong those 
conditions which involve shock and exhaus- 
tion. The antiseptic, vaginal douche after 
labor will promote healthy repair. 

Laceration of the perineum, an accurate 
diagnosis of which can be made only upon 
careful inspection, subsequent to labor, is 
caused by rapid descent of the head upon an 
unprepared perineum, by forcible impact of 
the posterior shoulder of the child, by incom- 
plete flexion of the head, and by failure to 
secure expulsion of the occipital portion of 
the head from the anterior vaginal commis- 
sure before extension is allowed to take 
place. The latter is the most common cause 
of perineal rupture. Immediate closure by 
sutures should be performed whenever cir- 
cumstances permit, though a correct appre- 
ciation and avoidance of the causes of the 
accident will do much in its prevention 

Rupture of pelvic joints. — The pubic ar- 
ticulation is most liable to this accident; the 
sacro-iliac joint less frequently and to a less 
degree. It is probable that when these rare 
events take place there is a succulency to the 



192 MANUAL OF OBSTETRICS. 

joint structures bordering on a morbid state, 
for we may meet with the accident when 
labor has easily accomplished the expulsion 
of a small child through an ample pelvis. The 
majority of instances are associated with 
prolonged and violent, though necessary, 
use of the forceps. Rupture at the sacro- 
iliac joint is partial and produces somewhat 
vague symptoms, as localized pain and diffi- 
cult locomotion. Separation at the symphy- 
sis pubis prevents locomotion, is attended by 
exquisite pain and tenderness at the joint, 
and movements of the pubic bones upon each 
other can be demonstrated. Recovery is te- 
dious, and will be aided by support of the 
pelvis by properly adjusted bandages. Many 
months may elapse before cure. 

PUERPERAL ECLAMPSIA. 

Puerperal convulsions are associated, in the 
great majority of cases, with imperfect per- 
formance of the renal function, and generally 
follow certain suggestive premonitory symp- 
toms, though they may occur unexpectedly. 
Frequency is once in three hundred or four 
hundred cases of labor. 

Causes. — Predisposing to eclampsia we may 
mention a nervous and excitable temperament, 



MANUAL OF OBSTETRICS. 193 

while we know that gestation brings about 
certain blood changes, as well as excitation of 
the nerve-centres favorable to the production 
of nervous disorders. Convulsive seizures 
may arise — in pregnancy as at other times — 
from hysteria, apoplexy, meningitis, poisons 
of fevers, cholcemia, hydrozmia as after 
haemorrhage, reflex irritation from the intes- 
tinal tract, violent emotion. Such outbreaks, 
however, as may be truly called "puerperal," 
arise either by: 1st, irritation of peripheral 
uterine nerves, by development of the pro- 
ducts of gestation, acting in a reflex way upon 
the general nervous system or upon the ner- 
vous system governing the renal function; or 
by, 2d, mechanical interference of the enlarged 
uterus with the return circulation from the 
kidneys, or with the function of the ureters. 
Associated with some of the above-mentioned 
causes, the immediate exciting influence will 
often be some special irritation of the partu- 
rient tract by the passage of the child, by 
catheter or forceps, or by hand of the atten- 
dant. 

Clinical history. — Previous to, and during 
labor we may observe indications of renal 
insufficiency leading to more or less uraemic 
poisoning. 



194 MANUAL OF OBSTETRICS. 

Albuminuria, with attendant symptoms 
and signs, suggest; probable danger, when the 
circulation is excited as in labor. Shortly 
preceding a convulsion we often have severe 
headache, vertigo, flashes of light, ringing in 
the ears, nausea, and vomiting, while oedema 
of face, labia majora, and extremities is gene- 
rally present. The convulsion — which may 
come without premonition — resembles that of 
epilepsy, the muscular twitchings beginning 
in the face and quickly becoming general. 
There is frothing at the mouth, venous tumes- 
cence of the face, and biting of the tongue. 
For a period succeeding the fit, varying from 
a few minutes to half an hour, the patient falls 
into a somnolent state, and then gradually re- 
covers mental power with no recollection of 
the circumstances of the attack. There may 
be no more seizures, or, at varying intervals, 
with increasing severity, there may occur a 
great number of fits, even fifty to one hun- 
dred. The attack may occur before, during, 
or after labor, each convulsion lasting one to 
four minutes. If before, we may expect the 
speedy advent of labor. 

Prognosis always grave to mother and 
child, the danger being greater according to 
the time which must elapse before delivery. 



MANUAL OF OBSTETRICS. 195 

Attacks occurring several hours after labor 
generally terminate favorably. 

Post-mortem examination reveals hyperse- 
mia, or degenerative changes in the kidneys, 
there being no characteristic brain lesion. 
The ureters and pelves of the kidneys have 
often been found dilated. 

Treatment, — Prophylactic measures have 
been mentioned in a previous part of the 
book. Treatment during a seizure consists 
in exercising care lest the patient sustain 
physical injury. Protect the tongue by in- 
troducing a cork or piece of wood between the 
teeth. 

Expedite labor by all measures which will 
not, at the same time, create too great periphe- 
ral irritation. Do not attempt to drag a child 
through an imperfectly dilated cervix, but 
by the gentle yet efficient Barries' bags pre- 
pare the cervix for the introduction of the 
forceps or for version. During all operative 
treatment employ chloroform, which not only 
renders operation more easy, but also lessens 
disturbance to the nervous system. The in- 
duction of premature labor in cases which 
threaten an attack of eclampsia has not 
shown results sufficiently favorable to war- 
rant its adoption except in extreme cases, 



196 MANUAL OF OBSTETRICS. 

especially those with conspicuous subjective 
signs. 

In all instances of present or threatening 
eclampsia, call upon the skin and bowels for 
thorough action. Diaphoresis and catharsis 
are efficient in reducing arterial tension, in 
relieving renal congestion, and, possibly, in 
eliminating uraemic poison. Elaterium or 
croton oil should be freely given, and by 
external applications of heat, as by hot blan- 
kets and hot bottles, perspiration induced and 
kept up. Blood-letting and veratrum viride 
will have sedative action upon the heart, 
when needed, and chloral in full doses by 
the mouth or rectum, morphia freely given 
hypodermically, and chloroform are useful 
agents to control the spasms. 

The renal disorder, after the convulsions 
subside, will usually promptly improve with- 
out treatment continued for more than a few 
days. It should always be remembered, how- 
ever, that chronic nephritis may result. 

PUERPERAL THROMBOSIS AND EMBOLISM. 

Coagulation of blood in the puerperal pa- 
tient is favored by the blood changes with 
excess of fibrin induced by pregnancy ; by 
the circulation of effete material in the blood 



MANUAL OF OBSTETRICS. 197 

during the degenerative changes in uterine 
structure attending involution ; and by weak- 
ened circulation when considerable blood has 
been lost, the haemorrhage also favoring 
hyperinosis. Disintegrating and separated 
coagula from uterine sinuses may serve as 
the starting points from which extensive 
coagula may form, though spontaneous coag- 
ulation is now believed to be possible. 

Clinical history varies much according to 
the situation and size of vessels involved, as 
well as upon the size of coagula. One class of 
cases producing very grave and sometimes 
suddenly fatal results arises from involve- 
ment of the right side of the heart and of 
the pulmonary arteries. Such cases may be 
of spontaneous, or of embolic origin. Usually 
the occurrence and nature of the complication 
is quickly and accurately recognized. From 
a normal puerperal condition there appear all 
the signs of serious pulmonary embarrass- 
ment. The blood fails to be oxygenated. 
We have violent dyspnoea, sense of thoracic 
constriction, gasping breath, pale or livid 
face, and a countenance indicating extreme 
suffering. The heart's action is irregular, 
usually tumultuous, sometimes fluttering , tvith 
radial pulse nearly imperceptible. Physical 



193 MANUAL OF OBSTETRICS. 

examination often reveals harsh or blowing 
murmur over the pulmonary arteries. Death 
may speedily supervene. In some cases the 
patient may rally and become more comfort- 
able, only to be quickly attacked again by 
similar paroxysms, which finally prove fatal. 
In a small number of instances recovery takes 
place. 

Treatment consists in aiding and steadying 
the circulation by ammonia, ether, or brandy, 
and requiring complete quiet. If the onset 
of the attack appears to be safely passed, it 
must be remembered that slight exertion 
may cause fatal renewal of the pathological 
process. 

Peripheral venous thrombosis (phlegma- 
sia dolens) is an affection in which we cannot 
but recognize as an important element in 
etiology, a blood dyscrasia. That there is a 
septic element in its causation in many cases 
is also believed. The pathological steps are 
generally in the following order — thrombus, 
phlebitis, and, accompanying the latter, in- 
flammation of the lymphatic vessels. Some- 
times inflammation of the vein precedes the 
formation of the thrombus, though, generally 
speaking, inflammation of the inner wall of 
the vein in itself does not lead to thrombosis. 



MANUAL OF OBSTETRICS. 199 

The veins most commonly involved in puer- 
peral thrombosis are the uterine, iliac, and 
femoral, in any or all of which thrombi may 
be found. The general tendency of such 
thrombi is to undergo absorption. Fragments 
may be detached from them, usually when 
they have existed some time and have be- 
come friable. These emboli may lodge in 
remote organs or parts and occasion further 
complications. 

Clinical history. — The disease begins in 
most cases between the fifth and eighteenth 
days after confinement, though instances 
are met with beginning as late as the end 
of a month. Pain, tenderness and stiffness of 
the affected limb are early symptoms, quickly 
followed by swelling. Fever is also present 
which may have been preceded by chill. Rest- 
lessness and malaise are present for a day or 
two before the local signs appear. Pulse is acceL 
erated, tongue coated, and bowels constipated. 
The swelling of the limb is produced partly 
by oedema and partly by the obstruction to 
the lymphatic circulation, the latter making 
it somewhat hard and brawny, not pitting 
much upon pressure. The pain may extend 
from above downward or from below upward. 
Tenderness is marked along the venous 



200 MANUAL OF OBSTETRICS. 

trunks, the femoral and popliteal veins often 
resembling large, firm cords when felt by the 
finger. After a week or ten days, the consti- 
tutional symptoms begin to subside, though 
general convalescence is much retarded. The 
limb also at this time begins to diminish in 
size, and pain and tenderness gradually dis- 
appear. Early efforts to use the limb are al- 
ways attended by aggravation of all the local 
symptoms, and it is usually many months 
before the limb resumes its natural state. 

Secondary septicaemia and pyaemia may 
arise. 

Suppuration in the affected limb is a rare 
result, though superficial ulcers are not un- 
common. Treatment should be light and sup- 
porting diet, quinine and iron, with anodynes 
and laxatives as indicated. Poultices, warm 
cotton or flannel, and rendering the limb im- 
movable in an easy position are required. As 
the limb begins to improve, warmth and sup- 
port should be given by evenly applied band- 
ages of flannel. Avoid, throughout, any 
traumatism which might lead to ulcers which 
are necessarily slow in healing. 

Remember, also, that as long as the veins 
contain any coagula there is the possible 
danger of detachment of fragments and seri- 



\ 



MANUAL OF OBSTETRICS. 201 

ous or even fatal embolism. All exertion 
should be guarded against for a long period. 

Peripheral Arterial Embolism may arise 
under the peculiar blood conditions of the 
pregnant and lying-in states, when fibrinous 
deposits are swept from the valves of the left 
heart into the circulation. The resulting 
condition of obstructed circulation in the 
part affected by the embolus does not call for 
description here, as it does not differ from 
that which is non-puerperal. 

Sudden death from other cases than pul- 
monary and cardiac thrombosis and embolism 
may occur as an extremely rare event. Air 
may enter the circulation after labor through 
the gaping uterine veins, if, by change of 
patient's position or by other means, it finds 
access to the vagina. The alternating con- 
traction and relaxation of the uterus favors 
its ascent into the uterus to take the place of 
expelled fluid contents. 

The presence of air, in considerable amount, 
in the circulation leads to fatal cardiac dis- 
tention and paralysis, or to asphyxia caused 
by minute air emboli in the small divisions 
of the pulmonary artery. 

Perilous and possibly fatal syncope may 
arise when there is afflux of blood to the large 



202 MANUAL OF OBSTETRICS. 

vessels of the abdominal viscera after the 
sudden diminution of uterine bulk consequent 
upon the birth of the child. A suspension of 
function of important cerebro-spinai centres 
results from the withdrawal of blood from 
them. 

PUERPERAL INSANITY. 

Under this head are included the various 
forms of mental derangement which are 
associated with pregnancy, the puerperal con- 
dition, and lactation. Mania and melan- 
cholia are the varieties met with. 

Causes, of which several usually co-exist, are 
hereditary tendencies, anaemia which may be 
simply the altered blood state of pregnancy, 
or may arise from successive pregnancies, en- 
feebling disease or hcemorrhage, urozmia, 
sudden, unusual or prolonged excitement 
from any cause. Some writers have urged 
that septic, while others that urazmic poison- 
ing explained the phenomena, but these claims 
have not been established. The depression 
of spirits of primiparai, especially if un- 
married, not rarely develops into melancholia 
or prepares the way for mania. 

Melancholia is the form of insanity which 
may occur in pregnancy, and may succeed 



MANUAL OF OBSTETRICS. 203 

(and must be distinguished from) hypochon- 
driacal apprehension of evil on the part of 
the patient. Perverted morale may be 
brought about in pregnancy in the same way 
that unusual tastes or cravings may be devel- 
oped. Insanity following labor by two or 
more weeks, and that of lactation is more apt 
to be melancholia than to be mania. Melancho- 
lia differs from mania in being insidious in 
its development, producing less systemic dis- 
turbance, running a longer course (from six 
months to several years if recovery takes 
place), being less fatal to life, yet more liable 
to the establishment of irremediable insanity. 
Symptoms. The earlier signs of melancho- 
lia are disturbed sleep, headache, mental de- 
pression, with some loss of appetite, and loss 
of strength. Next there are slight delusions 
of transitory nature. As these develope, the 
patient becomes much dejected, sleeps badly, 
is disinclined to bodily exercise, and melan- 
cholia becomes established. Suicidal tenden- 
cies are very common, as well as disposition 
to harm the offspring. The impulse which 
may sacrifice the mother's, or the child's life, 
often comes without warning, and closest at- 
tention must be given to guard against such 
an event. 



204 MANUAL OF OBSTETRICS. 

Mania commonly develops during or be- 
fore the second week after labor. For two or 
three days there will be premonitory symp- 
toms such as restlessness, headache, febrile 
action, and peculiar behavior. The patient 
soon becomes violent, displaying an unex- 
pected and extraordinary amount of strength. 
She may remain awake for twelve to eighteen 
hours raving wildly, and then have a heavy 
sleep of several hours, awakening only to re- 
sume incoherent, commonly profane and vul- 
gar language. Thoughts with reference to 
the sexual organs are common. The pulse is 
bounding and fast, the temperature high, 
tongue thickly coated, bowels constipated, 
urine high colored, and the excitement, which 
often prompts the patient to do violence to 
herself and to persons and objects about her, 
is intense. This may continue for days and 
weeks, producing more exhaustion upon at- 
tendants than upon the patient, or death 
may occur, prostration and great wasting of 
the tissues having taken place. The progress 
of the case will be much influenced by the 
amount of nourishment taken, for which 
there is often great disinclination. The fatal 
result is promoted usually by some co-exist- 
ing inflammatory condition. When recovery 



MANUAL OF OBSTETRICS. 205 

occurs, it is earlier, more complete, and more 
permanent than in melancholia. 

Upon autopsy, in cases of puerperal insanity, 
there are no distinctive lesions found. 

Treatment. — The surroundings of the pa- 
tient should be quietly cheerful, and every 
means taken to promote nutrition. Food 
must be administered in some way. If left 
within reach, the patient will sometimes help 
herself when she refuses it" from attendants. 
Rectal alimentation is sometimes necessary. 
Stimulants are to be used when exhaustion 
and debility are present. Sleep must be pro- 
cured by chloral and the bromides in full 
doses. Hot water to the head, and general 
bathing have soothing effect. Opiates may 
only be given when all other anodynes fail. 
In some cases there is present an hysterical 
element which calls for appropriate moral and 
medicinal treatment. Active circulatory ex- 
citement may be calmed by aconite. Blood- 
letting, blisters, and all depressing measures 
are contra-indicated. The bowels must be 
looked after, and fecal accumulation and im- 
paction recognized early by abdominal palpa- 
tion and digital examination per vaginam. 

Lactation must cease if that function is 
being performed. The infant should be re- 



206 MANUAL OF OBSTETRICS. 

moved from the patient's presence, lest it an- 
noy her, its removal seldom exciting any 
comment from the mother. 

The question of home or hospital treatment 
calls for the use of great judgment to be ap- 
plied to individual cases. In a general way 
we may say that mania may more properly 
be treated at home than melancholia. The 
circumstances of each case must be studied, 
especially the character of the patient, and 
that of friends and attendants. Carelessness 
or leniency are wholly unsuitable, and every 
cause for excitement must be removed. 

During convalescence, change of scene is 
very beneficial. 



CHAPTER X. 

PUERPERAL FEVER. 

Puerperal fever is a term of vague mean- 
ing, a relic of the views of earlier days when it 
was believed that certain serious and fatal 
illnesses which sometimes follow parturition 
depended upon a special, zymotic poison. At 
the present time we are able to classify the 
various affections, which were formerly in- 
cluded under the general name, under more 
appropriate titles with a clear understanding 
of their nature and manifestations, though 
some minor points in pathology are still un- 
settled. For convenience we may adopt that 
classification of Spiegelberg which is chosen 
by Lusk in his chapters which contain one 
of the most clear considerations of the subject 
available to the English-reading student. 



208 MANUAL OF OBSTETRICS. 

The febrile conditions of the lying-in period 
may be studied as follows: 

1. Inflammation of the genital mucous mem- 

brane, endocolpitis and endometritis. 

a, superficial; 6, ulcerative. 

2. Inflammation of the uterine parenchyma 

and of the subserous and pelvic cellular 
tissue. 

a, exudation circumscribed. 

£>, phlegmonous diffused, with lym- 
phangitis and pyaemia (lymphatic 
form of peritonitis). 

3. Inflammation of the peritoneum covering 

the uterus and its appendages, pelvic 
peritonitis and diffused peritonitis. 

4. Phlebitis uterina and para-uterina with 

formation of thrombi, embolism, and 
pyaemia. 

5. Pure septicaemia — putrid absorption. 

Apractical study of the clinical history and 
pathology of these affections as they present 
themselves in the puerperal patient leads to 
the conviction that there is in the vast major- 



MANUAL OF OBSTETRICS. 209 

ity of cases an underlying septic element in 
their causation. In a small proportion of 
cases, the febrile condition depends in the 
outset upon some one or more of these local 
conditions, there being no septic poisoning 
until a later period when the peculiarities of 
the puerperal patient favor and bring it 
about. We meet also a few rare instances of 
these conditions in which we may believe 
that we have simply the manifestations of 
local affections from beginning to end. The 
truth of this would be questioned by some, 
however, who would regard such cases as 
presenting the septic element, but in very 
mild form. Yet I cannot believe that the 
woman recently delivered may not suffer 
from cellulitis or peritonitis as well as that 
these diseases may arise unconnected witli 
child-bearing or septic infection. In almost 
every instance, however, in which we have 
full facilities for clinical and pathological ex- 
amination, even when organs remote from 
the parturient tract are the seat of lesions 
which have caused the fatal result, we are 
able to discover the indications of the absorp- 
tion of septic poison at some situation in the 
genital organs, and the progression of this 
poison to and into the general circulation, 



210 MANUAL OF OBSTETRICS. 

indications which, in the light of recent and 
accepted views upon septicemia as a disease, 
are unmistakable. 

The facilities for the introduction and de- 
velopment of septic poison in the lying-in 
woman are many, while the disease itself has 
inherent capability of development of peculiar 
intensity. Following parturition we have 
always the placental site and, in many cases, 
lacerations of the cervix, vagina, or peri- 
neum. If to these surfaces there is the con- 
tact of septic material, its absorption is 
extremely likely to occur. Prolonged con- 
tact or bathing of wounds with fluids con- 
taining this poison is much more likely to 
produce septicaemia, and that too of serious 
character, than contact for a short time, and 
the anatomical arrangement is such that we 
find retention of fluids in contact with these 
absorbing surfaces to be an easy thing. Un- 
til a wound is in a healthy, granulating, or a 
sealed condition, there is increased danger of 
septic absorption. In all puerperal wounds 
of the genital tract, their production by pres- 
sure, laceration, and bruising causes them 
to occupy a number of days before reaching 
a healthy condition of repair. The placental 
site, too, affords easy ingress to the poison, 



MANUAL OF OBSTETRICS. 211 

owing to the numerous large and often patu- 
lous uterine sinuses. 

Septic material may be brought in contact 
with the placental site and with wounds of 
the vagina in two principal ways, and we may 
divide our cases, therefore, into auto-genetic 
and hetero-genetic. 

Auto-genetic cases are those in which the 
septic poison originates with the individual 
who is sick. They are produced by decom- 
position of blood, fragments of secundines, 
inflammatory products, and sloughing tissues 
which are in close proximity to surfaces capa- 
ble of septic absorption. 

Hetero-genetic cases, or those in which the 
poison is supplied from other sources than 
the patient herself, arise from exposure to 
atmosphere containing emanations from pa- 
tients suffering from septicaemia, erysipelas, 
scarlatina, and diphtheria, or from direct 
contact and inoculation with secretions from 
such patients, other media than the atmo- 
sphere being carriers of the poison. Decom- 
posing animal tissues, pus, and blood also 
develop the virus of the disease. 

The introduction of the poison may be by 
unclean instruments of all kinds, by unclean 
hands, or through the air of the sick-room 



212 MANUAL OF OBSTETRICS. 

poisoned by any of the agents already men- 
tioned. 

Nature and mode of action of the septic 
poison. — Many and interesting are the studies 
upon these points, and it would be improper 
to omit some statement of the more advanced 
views of pathologists with reference to sepsis. 
There is so much, however, that is, and must 
be, speculative, that it seems wise to exercise 
some conservatism, and not too hastily to ac- 
cept these views, however ingenious they may 
be. The power of self-increase of the poison, 
until from a small amount of the putrid fluid 
there is extensive production of the contagi- 
ous principle throughout the whole body has 
led to the close scrutiny of the component 
parts of such fluid, and we have learned that 
there are universally present certain organ- 
isms, variably known as bacteria or micro- 
cocci. These are regarded as the contagious 
principleby many observers, and it is claimed 
that they enter the circulation through lesions 
of the capillaries, veins, and lymphatics, and 
undergo self -multiplication. The white blood- 
corpuscles are claimed to be the carriers and 
disseminators of the micrococci. It is farther 
known that in cases of septicaemia these or- 
ganisms are to be found at the presumed 



MANUAL OF OBSTETRICS. 213 

site of inoculation, along the lines of diffusion 
of the septic poison, in the blood itself, at the 
seat of the puerperal inflammations of dis- 
tant organs, as well as in the organs which 
perform duties of elimination. Accepting 
this view, rather than that of an essential 
zymotic poison, affords ready explanation of 
the multiform lesions of puerperal fever, 
this variation of lesion being chiefly due to 
the differing grades and extent of lymphatic, 
or vascular permeation. Another reasonable 
thought is that there may be variation in the 
quality and kind of this microscopic poison 
producing variety of lesion. If, as Lusk has 
aptly suggested, our best instruments fail to 
enable us to distinguish the ovum which is to 
produce a mouse from one that will produce a 
tiger, though the ovum is at least one hundred 
times larger than the micrococcus, is it not 
possible that these septic organisms are not 
always identical, though they have monoto- 
nous appearance of form ? This thought is 
in accord with views expressed by students 
of the subject. It cannot be doubted that 
these microspores play some important part 
in the development of septicaemia, though 
certain conservative observers are yet unwill- 
ing to give them an essential, etiological po- 



214 MANUAL OF OBSTETRICS. 

sit ion, preferring to regard them as one of the 
results rather than the cause of the affection. 
Returning to the classification of Spiegelberg, 
we have to consider first, 

Endocolpitis and Endometritis. — The 
simpler forms of these conditions are com- 
monly produced by prolonged or difficult 
labor, in which the genital tract sustains un- 
usual pressure and irritation from contact 
with the child. The vagina has superficial 
erosions and ulcers, giving rise to considerable 
purulent and sanguinolent discharge, exube- 
rant granulations being often found there and 
on the cervix. This discharge may be varia- 
ble in amount, and offensive at times. The 
labia are swollen, and there are pain, tender- 
ness, and heat in the genital region. The 
uterine cavity affords discharge containing 
some pus and blood, the uterus remains large 
and flabby, with some cede ma of the cervix. 
Mild traumatic fever continues for a few 
days until healthy repair is established. 

Another form of endocolpitis and endome- 
tritis known as ulcerative, diphtheritic, or 
septic, is much more serious. Here we find 
in the lining of the genital tract, deep and 
virulent extension of the ulceration until in 
some cases the deeper muscular structures 



MANUAL OF OBSTETRICS. 215 

are extensively laid bare. The ulcers have a 
grayish surface, which, in hospital cases 
chiefly, sometimes elsewhere, has a membra- 
nous character, not differing essentially from 
that of diphtheria; fibrinous fibrilloe, blood- 
globules, and micrococci being present. The 
dischargeis very offensive , brownish, and sero- 
purulent, containing fragments of necrosed 
tissue. These cases may terminate in general 
septic invasion, or, more commonly, after a 
febrile condition of a week or more, the ulcers 
take on a more healthy character, and recov- 
ery takes place. The process of healing 
should be watched in order that atresia 
vaginal may not result from agglutination of 
opposed ulcers. 

Metritis. — When the endometrium is in- 
flamed, the subjacent uterine structure parti- 
cipates to a greater or less extent in the pro- 
cess. Instances in which the muscular and 
connective tissues of the uterus are exten- 
sively involved are known under the name of 
metritis, which, as a disease, is never unasso- 
ciated with some of the other puerperal lesions. 
Originating sometimes from traumatic and 
sometimes from septic causes, it occasionally 
happens that there are not only molecular, 
but also necrotic changes, until a considerable 



216 MANUAL OF OBSTETRICS. 

portion of the structure of the uterus is lost. 
The earlier condition is one of ozdematous in- 
filtration of muscular and connective tissue, 
and the abundant, lymphatic network of the 
uterus takes up active morbid action. Collec- 
tions of pus and micrococci often form in 
parts of the uterus. The inflammation usually 
extends to adjacent structures, and blood- 
poisoning often occurs. The febrile distur- 
bance in metritis is of higher grade and more 
prolonged than in endocolpitis and endome- 
tritis. Pain is present with offensive puru- 
lent lochia. 

Parametritis (pelvic cellulitis) is the most 
common of the puerperal inflammations, and 
may be of non-septic or of septic character. 
In the former case the exudation, which may 
be localized or general, is of sero-lymphy na- 
ture, and the febrile disturbance is simply 
symptomatic of the inflammatory action, 
temperature ranging from 101° to 103°, pulse 
90 to 120. In the septic form there is an 
cedematous infiltration, local or general, in 
the cellular tissue surrounding the uterus. 
Micrococci are present in it, and the morbid 
process can usually be traced from a point or 
points of inoculation in the uterus along 
the lymphatics which, as well as the sinuses, 



MANUAL OF OBSTETRICS. 217 

generally contain pus. The febrile action is 
higher than in the non-septic variety (tempe- 
rature 103° to 105°), and there is greater con- 
stitutional depression as indicated by feeble 
and rapid pulse (130 to 140), profuse sweats, 
gastro-intestinal irritability, and nervous pros- 
tration. 

The local indications of parametritis are 
pain and tenderness, appreciated by supra- 
pubic and vaginal examination, usually more 
marked towards one broad ligament than 
towards the other. There may be diminished 
or increased and offensive lochia. Any at- 
tempt to examine regarding mobility of the 
uterus is very painful. Urination is slow and 
painful. If the exudation is general, the ex- 
amining finger obtains a sensation of fulness 
and bogginess. If, as often happens, the af- 
fection is unilateral, there will be an appre- 
ciable firm, tender swelling of circumscribed 
area. This exudation reaches its greatest 
extent about the end of the second week. 
There may be sufficient deposit to be recog- 
nizable in the iliac region. Cases may termi- 
nate in resolution, the inflammatory mass 
becoming less tender and smaller, gradually 
undergoing absorption. Suppuration may 
occur, the case be much protracted, and ab- 



218 MANUAL OP OBSTETRICS. 

scesses of considerable size may spontaneously 
discharge in the iliac region, vagina, rectum, 
or bladder. In all cases we are liable at any 
time to have septicemia and pycemia as 
grave and sometimes fatal complications. 

Perimetritis (pelvic peritonitis) is inflam- 
mation of that part of the peritoneum which 
covers the pelvic viscera. It is often asso- 
ciated with parametritis, owing to proximity 
of structure, and presents somewhat similar 
symptoms, though there are certain points of 
difference in the two diseases. There may 
be moderate exudation only — sufficient to 
impair the mobility of the uterus or produce 
agglutination of surrounding viscera. Occa- 
sionally the exudation is abundant, leading 
to a swelling in the iliac fossa, which may be- 
come as large as a good-sized orange, resem- 
bling that of cellulitis, though situated at a 
higher level, and less liable to suppuration. 
When of septic character, the lines of diffu- 
sion from the site of inoculation are apparent 
on autopsy, the exudation is purulent with 
presence of small sub-peritoneal abscesses, 
phlebitis and lymphangitis are present, and 
the ovaries are commonly inflamed and soft- 
ened. 

Symptoms are fever, pain, tenderness and 



MANUAL OF OBSTETRICS. 219 

tympanites in the hypogastric region, with 
absence of marked vaginal signs of cellulitis, 
it being remembered, however, that the con- 
ditions are often associated. There may be 
extension from pelvic to general peritonitis: 
or the pelvic peritoneal inflammation being 
secondary to septicaemia, the constitutional 
disorder may be more marked than the local 
signs. 

General, Peritonitis is common as a puer- 
peral affection, there being two principal 
varieties. One form arises as a result of sep- 
ticaemia, there having usually occurred me- 
tritis, cellulitis, or pelvic peritonitis, the lym- 
phatics being chiefly engaged in diffusing the 
poison (peritonitis lymphatica). Another 
form is primary, or an extension of the pelvic 
variety, there having been no — apparent at 
least — preceding septic absorption. In the 
septic form the pain and tenderness which 
one expects to attend general inflammation of 
the peritoneum are wholly secondary to the 
prostration of vital powers due to the blood 
poisoning. The abdominal cavity will con- 
tain fluid, sero-purulent exudation, greenish 
or brown, and offensive. The intestinal 
walls are distended, and after death will be 
found softened and readily torn. The disease 



220 MANUAL OF OBSTETRICS. 

comes on insidiously, sometimes no pain be- 
ing present of sufficient intensity to require 
opiates. Similar exudation is often found in 
the pleura and pericardium associated with 
septic peritonitis. Loose diarrhceal move- 
ments are not uncommon. The most promi- 
nent sign on which to base a diagnosis will be 
marked, persistent abdominal distention, 
there being indications of septicemia. There 
may be no marked septic lesions in the uterus 
and its appendages. 

General peritonitis, when its septic origin 
is absent or doubtful, affords abundant lym- 
phy exudation with some pus. The abdomi- 
nal organs become agglutinated. The febrile 
movement is attended by high temperature, 
severe pain and inflammatory excitement, 
followed usually by prostration. Vomiting, 
delirium, tympanites and constipation are 
common, the latter often followed by diar- 
rhoea. A severe chill is sometimes the initial 
symptoms of the attack. 

Septicemia is a disease of protean charac- 
ter. It may be of such virulent type that 
blood dissolution is the only lesion, death 
occurring before the development of any sep- 
tic inflammation. In such cases all the 
organs are softened, and the blood shows 



MANUAL OF OBSTETRICS. 221 

little or no disposition to post-mortem coagu- 
lation. The temperature rapidly rises to a 
high degree (upwards of 106°), extreme nerv- 
ous prostration occurs, and death may result 
in from twenty-four to forty-eight hours. If 
the disease takes a less intense course, though 
of the same general character, the tempera- 
ture may continue between 104° and 106 ° for 
several days, vomiting, delirium, and some- 
times diarrhoea will be present, few patients 
recovering, the duration of the attack being 
less than a week. 

In other forms of septicemia the blood 
poisoning is not so virulently felt, though the 
results may be as serious. The diffusion of 
the poison is more gradual, its effects are less 
striking, and the patient may succumb after 
many weeks of suffering, or finally recover. 
When purulent infection occurs, the symp- 
toms are clearly demonstrable after the second 
week. Chills and profuse sweats recur, the 
temperature rises and falls, though never 
reaching normal, the stomach is irritable, 
the skin becomes yellow, tongue coated and 
disposed to be dry, low delirium and halluci- 
nations are at times present, the mental 
faculties are dull, and the respiration is shal- 
low and hastened. There will be the indi- 



222 MANUAL OF OBSTETRICS. 

cations also of some one or more of the 
local, septic inflammations which have al- 
ready been described in the preceding pages. 
Peritonitis is present in fewer than half the 
cases. Metastatic abscesses, as the result of 
the blood changes, or of infected emboli are 
common in the lungs, kidneys, liver, and 
about the joints. Hematogenous icterus may 
occur and is to be regarded as a grave symp- 
tom. 

Prevention and treatment of puerperal 
fever. We encounter more cases of puerpe- 
ral fever in hospital than in private practice, 
and it is in the former that prophylaxis be- 
comes a question of great moment. An at- 
mosphere uncontaminated by germs such as 
are developed by surgical cases, and those of 
zymotic poisoning, as well as by previous 
cases of puerperal fever, is necessary to the 
safety of lying-in patients. Inasmuch as the 
poison can be conveyed from place to place, 
physician, nurse, laundress, and visitors to 
the sick-room should exercise great care lest 
they be the bearers. Bedding, clothing of at- 
tendants, hair and whiskers, instruments, 
hands, and especially finger nails are the 
media by which the poison may be conveyed 
to the patient. In prolonged labors it is 



MANUAL OF OBSTETRICS. 223 

necessary — in all cases proper— to employ dis- 
infectant vaginal injections during labor. 
After labor and in advance of septic indica- 
tions, their not too frequent but judicious use 
is called for. The proper management of the 
third stage of labor, looking to the complete 
expulsion of secundines and clots, and to per- 
manent, uterine contraction, is important in 
the prevention of both auto and hetero-inocu- 
lation. 

In puerperal disorders which, in their in- 
ception, are not complicated by septicemia, 
treatment does not differ essentially from that 
suited to cases of the same nature unconnect- 
ed with parturition, except that special care 
is necessary, on account of the tendencies of 
lying-in women, to use the disinfectant 
douche, and to promote escape of pus from 
mucous surfaces and from abscess cavities. 
In cases of septicaemia, by the same means we 
avoid accumulation of the poison germs and 
re-infection. When the point of inoculation 
is in the uterine cavity, or when we know that 
this cavity contains decomposing fluid, warm 
and carbolized intra-uterine injections should 
be repeated every few hours, and they will 
usually cause prompt fall of temperature. 
Care is necessary that the injections be made 



224 MANUAL OP OBSTETRICS. 

slowly and the liquid be freely allowed to es- 
cape so as to avoid dangerous uterine disten- 
tion, extension of the fluid into the perito- 
neal cavity, shock, and retention of poisonous 
material. 

Sloughing tissues should be removed as 
early as possible, and contiguous, exposed 
surfaces should be covered with iodoform in 
powder form or suspended in glycerin, in a 
ten-per-cent mixture, or touched with car- 
bolic acid, or with tincture of iodine. 

In local or general parametritis the early 
use of leeches may lessen the extent of inflam- 
mation. When exudation is present, vagi- 
nal injections of hot water (110° F.) hasten its 
absorption, and external application of heat, 
as by poultices, is proper when the situation 
of the pelvic inflammation makes it practi- 
cable. Pelvic abscesses should be treated by 
aspiration or incision. In peritonitis, light 
warm poultices of bran or flaxseed are advis- 
able. 

Medicinal treatment should consist of opi- 
ates to relieve pain, quinine, judiciously, for 
its antipyretic and supporting effect, and 
stimulants when indicated. Food should be 
concentrated, nutritious, and easy of diges- 



MANUAL OF OBSTETRICS. 225 

tion. The importance of maintaining unim- 
paired digestion cannot be over-estimated. 

General blood-letting, at any stage of septi- 
caemia, is improper. Arterial sedatives, as 
aconite or veratrum viride, may be useful in 
certain cases characterized by circulatory ex- 
citement, yet their depressing effect is so easily 
reached and such close observation during 
their use is necessary that great caution 
should be displayed with them, lest they be 
administered too freely or in unsuitable cases. 

Salicylic acid, as well as quinine, given in 
large doses may reduce the temperature, and 
the wet pack, with careful avoidance of its 
depressing effect, is similarly suitable. 

Tympanites, when excessive, causes pain 
and a depressing reflex influence on the nerv- 
ous system. Stimulating enemata containing 
assafcetida or turpentine, or even abdom- 
inal puncture of the intestines by fine aspira- 
tor needles will afford some relief. 



CHAPER XL 

OBSTETRIC OPERATIONS. 

The Forceps. — Delivery of the child by 
aid of the forceps constitutes the most com- 
mon of the obstetric operations, and according 
to the situation of the child at the time of 
the operation, and to the conditions calling 
for the use of the instrument, the operation 
may be simple and easy, or tedious and dan- 
gerous, requiring great knowledge and skill. 
The value of the instrument lies chiefly in the 
facilities which it affords for making traction 
upon the fetus, and compression of the head. 
To the instrument has also been credited cer- 
tain power as a lever, but this has been much 
exaggerated. 

The forceps is composed of two separate 
parts, this disunion allowing of its more easy 
application. When viewed as a whole, we 
find one end of the instrument adapted for 
grasping the head of the child, while the 



MANUAL OF OBSTETRICS. 227 

other end is constructed to be conveniently 
held by the operator. The fetal end of the 
instrument is composed of two blades, each 
having a concave surface to fit the convexity 
of the fetal head. The blade is usually fene- 
strated to make the instrument lighter, to 
more evenly distribute the pressure which 
may be called for, and to avoid adding, to the 
width of the fetal head, the thickness of solid 
blades. 

The forceps may be " long" in which case, 
when the head is in the grasp of the blades 
while yet at the pelvic brim, the handles will 
be wholly external to the vulva. " Short " 
forceps, having little or no shank, suffice to 
reach the head when it has descended into 
the pelvic canal. Straight forceps are those 
having the handles continued in a line with 
the blades. The "pelvic curve' 1 is found in 
the long forceps of the present day, being sit- 
uated in the shank and beginning of the 
blades. It is intended to adapt the instru- 
ment to the curve of the pelvic canal so that 
when the blades are applied and in the axis 
of the superior strait, the handles may pre- 
sent themselves at the vulva lying very nearly 
in the axis of the pelvic outlet. The " ce- 
phalic curve " is found in each blade and 



228 MANUAL OP OBSTETRICS. 

adapts it to the convex surface of the child's 
head. The "perineal curve" is a term now 
coming into use in connection with the for- 
ceps of Tarnier, and will be described later. 
The loch is at the crossing of the two halves 
of the instrument and keeps them symmetri- 
cally placed during extraction. A device of 
some kind is generally found at the end of 
handles for the purpose of enabling the oper- 
ator to regulate the amount of compression 
to be applied to the child's head. It would 
not be wise here to enter upon a description 
of the differences existing among the instru- 
ments bearing the names of Naegele, Smellie, 
Levret, Simpson, Hodge, Elliot, Bedford, Tay- 
lor, Wallace, and of others. In principles of 
construction they are alike. In such details as 
the form of the lock: length, breadth, thick- 
ness, or shape of the blade: shape of handle, 
etc., are variations. In great measure the 
preference for one instrument over others de- 
pends upon early teaching or custom in us- 
ing. 

The instrument of Tarnier deserves some 
separate mention, however, as having some 
original modifications. It is intended for use 
in high operations, being especially adapted 
to those labors in which the head is disposed 



MANUAL OF OBSTETRICS. 229 

to impinge upon the pubic border at the su- 
perior strait. In such cases certainly, and in 
high operations generally, the instrument of 
Tarnier is superior to others in accurately 
grasping the head, and effecting delivery with 
the least possible risk to maternal parts. In the 
forceps of Tarnier the handles, instead of be- 
ing continued in the direction of the shank, 
are, by a backward bending of the shank, di- 




Fig. 44.— Forceps of Tarnier. 

rected more backward than in the common 
forceps. The handles lie on a plane about 
three inches above the posterior curve of the 
blades. To the posterior curve of the blades 
at the ends nearest the handles are two mov- 
able traction rods to which can be attached 
the traction handle which latter has a deep 
curve, concave toward the perineum. By this 
latter handle when traction is made, with the 



230 MANUAL OF OBSTETRICS. 

blades within the superior strait of the pel- 
vis, the force is in reality applied in the line 
of the axis of the superior strait. 

In the selection of ordinary forceps there 
should be care to avoid blades which are thin 
and have considerable spring. Besides the 
danger of lacerations by thin edges, there is 
greater risk of fatal compression of the child's 
head. The springy blades, when traction is 
made, slip forward in the direction of the ope- 
rator, the tips of the blades become separated 
more than is intended, yet owing to the elasti- 
city of the blades their tips impinge with 
great force, at their points of contact, upon 
the head. Narrow or short handles are ob- 
jectionable. 

Indications for the use of the forceps have 
been mentioned in connection with the vari- 
eties of unnatural and complicated labor. 

Preliminary to the operation, which in this 
country is always performed with the patient 
on the back, the bladder should be emptied 
by a new, gum elastic catheter, the rectum 
cleared of fecal matter, and an anaesthetic 
administered in all cases unless the head is 
well descended to the pelvic outlet. Even 
then an anaesthetic is preferred by many. 
After turning the patient crosswise in the 



MANUAL OF OBSTETRICS. 231 

bed, with her hips close to its edge, with a 
sufficient number of assistants to steady the 
limbs and afford other help, the forceps are 
to be applied after having been warmed and 
oiled. 

High operations should not be performed, 
as a rule, until the os is dilated. Occasion- 
ally the blades of a narrow forceps, like Tay- 
lor's, may be introduced within a cervix 
which is two-thirds dilated, and, with gentle 
force, dilatation may be completed by the 
aid of the instrument, the head being drawn 
against and into the os. 

The lower blade should be the first to be in- 
troduced, and with two fingers of the right 
hand, palm upward, passed into the vagina 
until their tips touch the head, the blade 
should be carried gently upward until it 
reaches and begins to pass between the sa- 
crum and the head. Then directed in a com- 
bined upward and lateral direction, it finally 
reaches the left lateral part of the pelvic 
brim, with its concavity against the head, 
looking toward the right side of the pelvis. 
In passing the cervix, the tip of the blade 
should be kept well against the head. There 
being more room toward the sacral wall of the 
pelvis, it requires less force to introduce the 



232 



MANUAL OF OBSTETRICS. 



blade there, until it lies upon the head, then 
to be turned laterally, than to attempt from 




Fig. 45. 
the outset to pass it in at the left side of the 
pelvis. After this blade has reached its des- 



MANUAL OF OBSTETRICS. 233 

tination, the handle should be depressed to- 
ward the rectum and held by an assistant. A 
similar manipulation should be used to intro- 
duce the other blade, with reversal of the hands 
of the operator in the part which they take, 
and if the blades are situated in their proper 
places, locking will readily take place. The 
nearly symmetrical position of the forceps to 
the pelvis when thus applied constitutes the 
' ' pelvic application. " In the * ' cephalic appli- 
cation " indorsed by some obstetricians, it is 
sought to place the blades laterally to the 
child's head without regard to the relation of 
the latter to the pelvis. Traction should be 
made so as to cause the head to descend in 
the axis of whatever part of the pelvis it oc- 
cupies, and as the pelvic canal is curved to a 
marked degree, the direction of the traction 
force has to be changed frequently during de- 
scent. At first the handles must be held so 
far posteriorly as to depress somewhat the 
perineum. Intermittent traction should be 
employed, the force applied during labor 
pains. 

In the intervals between pains, traction 
should be relaxed, and occasionally the head 
liberated from all compression. If the head 
has been grasped by the forceps when lying 



234 MANUAL OF OBSTETRICS. 

in a transverse or oblique position, a tendency 
to rotate during descent will be present usu- 
ally, and should be noted, the forceps being 
removed and re-applied to the head in the 
new position which it assumes. 

Steady downward force is preferable to a 
lateral, pendulum motion, though when there 
is very firm impaction of the head, the latter 
motion may safely serve to start the head 
from its fixed position. Hasty delivery ex- 
poses the patient to dangers of contusion and 
laceration, haemorrhage, and shock which 
may evoke complications which cannot be 
counterbalanced in any way. Descent of the 
head from the uterus into the vagina until it 
reaches the hollow of the sacrum gives us the 
condition which, if occurring spontaneously, 
there then being delay, would call for the 
" low operation." The advice already given 
regarding the application of the instrument 
suggests readily the method to be followed in 
these cases. 

When the head reaches the pelvic outlet 
and the forceps is in use, traction should be 
straight out from the vulva. While the head 
is passing the tuberosities of the ischia which 
are the last of the bony points to offer obstruc- 
tion, moderate as well as intermittent force 



MANUAL OP OBSTETRICS. 235 

must be employed in order that distention of 
of the perineum be gradual. We seek to 
imitate as far as possible the natural method 




Fig. 46.— Low operation, 
by which the resisting perineum can be 
stretched and dilated without rupture. It is 
always better that twenty minutes to half an 



23G 



MANUAL OF OBSTETRICS. 



hour be occupied in the passage of the head 
past the perineum. As the head seems about 
to emerge, remove the forceps, the handles 
of which by this time have been directed 




Fig. 47. 
very much forward, using no force in so 
doing. 

Safety to the perineum will depend upon 
its gradual distention by alternate descent 
and recession of the head, by removal of the 



MANUAL OF OBSTETRICS. 237 

forceps before the passage of the head, by 
maintaining flexion of the head with the fin- 
ger in the rectum, while, at the same time, 
the perineum is drawn forward, and by com- 
plete emergence of the occiput before the pas- 
sage of other parts of the head. 

If labor has been of long duration and the 
parts are dry, use vaseline freely, remember- 
ing also that, at no time, is full obstetric an- 
aesthesia of as great importance as at this. 
During the entire time that the forceps is ap- 
plied to the head, the latter should be fre- 
quently touched to note its advance and its 
relation to the instrument. 

Forceps to the after-coming head.— 
There are times when the instrument is 
called for in delivery of the head after the re- 
mainder of the child, which has presented by 
the breech, has been born. In the great 
majority of breech cases, no more can be 
done by the aid of the instrument than by 
manual efforts at extraction, and valuable 
time would be lost during the putting on of 
the blades. 

The instances in which the instrument is 
indicated — and should be at hand, warmed 
and oiled — are : cases in which there is 
known to be a pelvis diminished in its diame- 



238 MANUAL OP OBSTETRICS. 

ters, the labor being at term with a child of 
average size; instances in which the head is 
caught at the superior strait owing to dispro- 
portion between pelvis and head, or from ex- 
tension of the latter; finally, when manual 
efforts, properly applied during a reasonable 
time, fail to cause any advance of the head. 

Application, — If the head is low down with 
the chin posteriorly situated, let an assistant 
lift the child's body forward toward the ab- 
domen of the mother, have the perineum de- 
pressed, and the vagina and child's mouth 
cleared of mucus to allow, if possible, access 
of air to the child's lungs, apply the blades 
with celerity, and, making traction with the 
handles brought well forward, delivery may 
be effected quickly. 

If the head is caught at the brim, more 
difficulty will be encountered, and care must 
be taken that the funis is not pinched. If the 
head is extended, with the chin anterior, we 
seek by the forceps to bring the occiput into 
the hollow of the sacrum, and then by trac- 
tion to deliver the head. If extension of the 
head exists, the occiput being anterior, we 
seek to bring the face into the sacral excava- 
tion. If the head resists the forceps and ex- 
tension persists, the child being known to be 



MANUAL OF OBSTETRICS. 

dead, it is better to diminish the diameters of 
the head by perforation and cephalotripsy 
than to incur the great risk of extensive 
laceration of the perineum by dragging down 
the head in a condition of extension. 

In occipito-posterior, vertex cases, it 
must be remembered that, as the head 
emerges, the condition of flexion remains 
until the head is entirely born. As the head 
is passing the pelvic outlet, we do not, there- 
fore, bring the handles forward toward the 
mother's abdomen, but, rather, depress them, 
in order that the face and chin may pass out 
from beneath the pubic arch. 

In face presentation, the case being so 
far progressed that conversion into the ver- 
tex is impossible, the forceps is a proper aid 
to delivery if delay calls for help. In cases 
with the chin anterior, the blades must be 
inserted sufficiently far to securely grasp the 
occiput. In mento-posterior cases, the for- 
ceps may effect delivery with, almost invaria- 
bly, death of the child and injury to the 
mother. Anterior rotation of the chin can- 
not be accomplished with the instrument, its 
application usually retarding, even, any ten- 
dency to spontaneous rotation. 



240 MANUAL OF OBSTETRICS. 

CRANIOTOMY AND EMBRYOTOMY. 

Craniotomy is an operation by which the 
child's head is reduced in its diameters by 
perforation, by mechanical crushing, or by 
both. That operative procedure by which 
the head is crushed is called cephalotripsy. 

When, as in these measures, the life of the 
child will be destroyed, there should have 
been careful deliberation to decide that other 
operations which are not sacrificial to the 
child may not afford the same safety to the 




Fig. 48.— Smellie's scissors. 

mother as craniotomy. When we have to 
do with cases where there is known to be 
death of the child, craniotomy may be em- 
ployed properly, even more frequently than 
is common, in order to diminish the minor 
risks to the mother which attend labor 

Instruments for perforation. — The most 
useful of the early instruments for this -pur- 
pose is Smellie's scissors. 



MANUAL OF OBSTETRICS. 



241 



Of this there have been various modifica- 
tions, two of which can be warmly recom- 
mended, viz., Simpson's perforator and Blot's 
instrument; that of Thomas should be men- 
tioned also, which, by its gimlet point, is 
especially safe from slipping. 

These instruments are intended to perfo- 
rate the skull, enlarge the opening originally 




Fig. 50.— Blot's perforator. 



made, break up the brain, and assist in dis- 
lodging it from the cranial cavity. An 
instrument similarly used, also, is the tre- 
phine perforator which removes a circular 
piece of bone. An opening of this shape, 
I however, does not best prepare the way for 
crushing, and the instrument is complicated, 
requiring much care to be kept in order. 



242 



MANUAL OF OBSTETRICS. 



Another class of instruments is intended 
for removal of portions of the cranial bones, 
serving also in some instances for applying 
traction. 




Fig. 51.— Braun's cranioclast. 




Fig. 52.— Simpson's cranioclast. 




Fig. 53. 
The cranioclast and craniotomy forceps are 
employed to seize the thin cranial vault lying 
adjacent to the opening made by the perfo- 



MANUAL OF OBSTETRICS. 243 

rator, one blade of the instrument being 
passed into the skull, the other lying on the 
outside. After approximating the blades 
firmly, a wrenching and twisting motion will 
serve to tear away that part of the skull in 
the bite of the instrument. Portion after 
portion may be successively grasped and re- 
moved, and the head much reduced in size 
though the base of the skull cannot be affected 
much by the use of the instrument. Direct 
traction also may be made for the purpose of 
aiding delivery, the heavy instrument of 
Simpson, or of Braun, being preferable. The 
cranioclast may be used advantageously, also, 
to supplement the cephalotribe, which is yet 
to be described. The delivery of the trunk 
may be facilitated by the use of the cranio- 
clast as a tractor, one blade being introduced 
into the thorax, usually between the scapula 
and clavicle. Another instrument for extract- 
ing after perforation is the crotchet. This is 
intended to be introduced through some nat- 
ural or artificial opening in the fetus, and 
hooked on to the border of the opening. 
While the crotchet is an instrument of some 
value, its use is always attended by danger 
from its tearing free from its hold and inflict- 
ing wounds upon the maternal soft parts. 



244 MANUAL OF OBSTETRICS. 

The blunt hook may be used for the same 
purpose as the crotchet, in some instances 
quite as effectively, and with greater safety. 

The cephalotribe is a powerful instrument 
for crushing the skull after, or without 
previous perforation. Its value depends up- 
on its power to reduce in size the base of the 
skull. It consists of strong, unyielding, 
rather narrow blades with handles, arranged 
as in the forceps, though when the two halves 




Fig. 54.— Blunt hook and crotchet. 

of the instrument are fully approximated, the 
space between the centre of the blades is not 
more than two inches across. The instrument 
flattens the head in the diameter in which it 
is applied, by making numerous partial, and 
sometimes complete, fractures. By its reap- 
plication in a different diameter than the one 
first seized, the crushing can be made very 
extensive. 

Operation. — The bladder and rectum being 
empty, the patient anaesthetized and properly 
placed for operating, the perforator is made 
to impinge perpendicularly upon the pre- 



MANUAL OF OBSTETRICS. 245 

sen ting part slightly anterior to the axis 
of that part of the pelvic canal in which the 
head is situated. In passing the instrument 
chrough the vagina, its point must be held 
carefully against two fingers of the left hand 
which have been previously introduced and 
are touching the head. By a boring motion 
the instrument is made to enter the cavity of 
the cranium, care being taken that it does 
not slip from the head and wound maternal 
structures. Unless the head is firmly en- 
gaged in the pelvis, it must be steadied by 
the hands of an assistant placed in the supra- 
pubic region. After the instrument enters 
the skull it should be swept in every direction 
to break up the brain, and its point directed 
to the medulla oblongata, in order that no 
mutilated yet living child may be subse- 
quently born. 

Carrying the instrument deep into the skull, 
and causing separation of its blades enlarges 
the opening so that the brain matter may es- 
cape, this being facilitated by uterine action 
which is occurring at short intervals. If no 
subsequent operative measures are intended, 
perforation may be performed when the cer- 
vix is moderately dilated, though the greater 
the dilatation the greater is the ease and safety 



246 MANUAL OF OBSTETRICS. 

of even this step. To assist in fixing the head 
in these early operations the forceps, applied 
for that purpose, may be useful. 

Perforation of the after-coming head is 
usually performed in the mastoid or occipital 
region, the body being held well out of the 
way towards the opposite side. 

After the measures described have been ta- 
ken, sufficient reduction in the size of the 
head may have been accomplished to permit 
of spontaneous delivery. Ordinarily, how- 
ever, some instrumental help will be called 
for, owing to the already prolonged labor and 
to the conditions requiring that which has 
already been done. In some instances the 
forceps is sufficient, in others the cephalo- 
tribe is indicated. 

Previous to the use of the latter instrument, 
the cranioclast may be employed for purposes 
already mentioned. In using it, care must be 
taken lest sharp fragments of bone injure the 
cervix or vagina, the scalp, which has not been 
been removed with portions of skull, being ad- 
vantageously turned in so as to cover the edge 
of the enlarged opening if efforts at extraction 
are made. One advantage attending the use 
of the cranioclast as a tractor is, that after re- 
moval of the greater part of the cranial vault, 



MANUAL OF OBSTETRICS. 



247 




Fig. 55.— Lusk's cepha- 
lotribe. 



the face can be brought 
down so as to secure 
diameters, which are 
very much shortened, 
to pass through nar- 
rowed pelvic diame- 
ters. 

The cephalotribe 
may be used without 
the previous employ- 
ment of the cranio- 
clast, or, in the more 
extreme cases of de- 
formity, after its use. 
It is chiefly of value 
to reduce in size the 
base of the skull, and 
for extraction, no 
other means being as 
suitable for the for- 
mer object. In cases 
promising to be diffi- 
cult, it is advantageous 
to wash out, by syr- 
inge, all brain matter 
from the skull. The 
blades of the cephalo- 
tribe should be intro- 



248 MANUAL OF OBSTETRICS. 

duced in the same manner as those of the for- 
ceps, in the transverse or oblique diameter, 
being carried as high as possible. In general 
terms it may be said that, in slight degrees of 
pelvic deformity, this instrument may be used 
for crushing and traction; in the greater de- 
grees of deformity, for crushing alone. Re- 
peated crushing in several diameters of the 
skull gives the most complete results, though 
in extreme deformity, contusion of maternal 
parts must be avoided in such procedure. 
The principles which govern delivery by the 
forceps apply in delivery by the cephalo- 
tribe. 

The instrument may be used without pre- 
vious perforation when slight disproportion 
exists. In all these operative measures, the 
general condition of the patient should be 
watched, and suitable stimulation, external 
warmth, etc., employed, in some instances it 
being desirable to interrupt the operative 
measures for a time, in order to afford rest to 
the patient. 

EMBRYOTOMY. 

Embryotomy, by general consent, means 
the removal of the child by fragments, the 
operation being limited to parts other than 
the head. 



MANUAL OF OBSTETRICS. 249 

It is called for by extreme pelvic deformity, 
as in an impacted shoulder case, or to deliver 
the body after craniotomy, or in fetal mal- 
formations, and tumors of thorax or abdomen. 

Evisceration is accomplished by opening 
the thorax or abdomen with a perforator al- 
ready described, or by strong scissors, the 
fetus having been brought as low in the pel- 
vis as possible. The opening having been en- 
larged, the perforator may break up, and 
vulsellum forceps seize and remove the 
viscera. The ribs, spinal column, and mus- 
cular structures can be best removed by the 
strong scissors. Previous to such measures, 
the disinfectant douche of the bichloride of 
mercury, 1 : 2000, should be employed. Great 
care should be taken during the entire opera- 
tion that maternal parts be not wounded by 
instruments or by fragments of bone. In 
impacted shoulder cases, if the thorax be the 
part most accessible, after its reduction and 
after division of the spine with the scissors, a 
phenomenon like spontaneous evolution can 
be artificially induced by traction on the in- 
ferior part of the child. 

Decapitation may be necessary when, in 
impacted shoulder cases, the neck is near the 
centre of the pelvic canal. There are instru- 



250 MANUAL OF OBSTETRICS. 

ments especially devised for this, as Braun's 
decapitating hook which is carefully passed 



^ 




Fig. 56.— Braun's hook. 

over the neck, and which, by alternating 
twists of the operator's hand, breaks the bony 
structures. After, or even without this, the 
strong scissors sever the body from the head. 
In all these measures, bring the neck as low 
in the pelvis as possible. A chain saw, or 
stout whip cord passed over the neck by an 
instrument devised for the purpose, or impro- 
vised from a catheter, will readily saw the 
neck apart. The maternal structures must be 
protected by some sort of tube, as a metallic 
cylindrical speculum, passed over the free ends 
of the cord or chain into the vagina as far as 
it can go. For withdrawing the eviscerated 
body the crotchet is useful, being much more 
safe than when used for traction upon a perfo- 
rated head. 
If the head is the last part of the child to 



MANUAL OF OBSTETRICS. 251 

be delivered, the body having beeen sepa- 
rated from it, the forceps, or the crotchet in- 
troduced into the foramen magnum, will be 
suitable. Other instruments have been de- 
vised for various purposes in connection with 
decapitation and embryotomy. They are 
not sufficiently necessary, however, to come 
into common use, and a description of them 
would not be called for by the scope of this 
book. 

VERSION, 

Version, one of the oldest of the obstetric 
operations, is the substitution of one portion 
of the child for some other, as the presenting 
part. 

Indications are such existing conditions as 
make delivery impossible or difficult, as in 
shoulder or side presentations, and pelvic de- 
formity : certain relations of the uterine con- 
tents which imperil the safety of the child, as 
face or brow presentation, prolapse of the 
funis: and conditions which call for rapid 
delivery, as placenta previa, accidental haem- 
orrhage, convulsions. Two principal varie- 
ties are cephalic and podalic version. 

In cephalic version, the head is substituted 
for some other portion of the child which is 
presenting. In view of the fact that when 



252 MANUAL OF OBSTETRICS. 

successful, we have brought about a condi- 
tion which offers greater safety to the child 
than after podalic version, and, if unsuccess- 
ful, the original condition remains unchanged, 
no complication having been added by the 
measures undertaken, cephalic version should 
be attempted with greater frequency than is 
common. It should not be attempted if haste 
in delivery is necessary, or if the fetus is not 
freely movable at the brim, presence of liquor 
amnii making success more probable. 

Cephalic version should be attempted either 
by external manipulation or by combined ex- 
ternal and internal method. 

External Version, when employed to cor- 
rect shoulder presentation by bringing the 
head to the superior strait, does not differ es- 
sentially from the operation when performed 
to make the breech the presenting part. Inter- 
vals between uterine contractions must be se- 
lected as the time suitable, and, after abdom- 
inal palpation has indicated to the operator 
the exact position of the child, such manual 
alteration of its position should be attempted 
through the abdominal and uterine walls as 
will bring the long diameter of the child per- 
pendicular to the pelvic brim, with either the 
head or breech presenting, as may have been 



MANUAL OF OBSTETRICS. 253 

desired. To relax the abdomen, the limbs 
should be drawn up, and chloroform is always 
extremely useful during the operation. In ad- 
dition to the hands of the operator, those of an 
intelligent assistant may be an aid. Repeated 
and somewhat varied pressure upon the two 




Fig. 57.— External version. 

poles of the fetus, seeking to bring one fetal 
end to the pelvic brim and the other toward 
the ensif orm cartilage, must be made. Liber- 
ate the fetus from any fixed position which it 
may have from contact with maternal parts, 
seeking to float it in the liquor amnii. What- 



254 MANUAL OP OBSTETRICS. 

ever gain is accomplished from time to time, 
must be held by carefully steadying the fetus 
in its new position. 

Placing the woman on the side toward 
which the head is directed may facilitate 
turning by causing the fundus uteri and con- 
tained breech to gravitate in that direction, 
this having the effect of bringing the head 
upward toward the pelvic brim. After suc- 
cessful version brought about in this way, 
the membranes must be ruptured and uterine 
contractions encouraged in order to fix the 
new presenting part in the pelvic inlet. Even 
then close attention must be given to note a 
tendency to, and prevent, return to the origi- 
nal presentation. To prevent return, the 
fetus must be steadied in its corrected posi- 
tion by the hands kept upon the abdomen for 
some time. A binder with pads placed 
laterally to the child is of advantage in some 
cases to effect the same result. 

Combined External and Internal Ver- 
sion may be undertaken in about the same 
class of cases as those suitable for external 
version. To these may be added cases in 
which it is necessary to lift the shoulder or 
arm from slight engagement at the brim. 
The membranes may or may not have been 



MANUAL OF OBSTETRICS. 



255 



ruptured, the latter condition, or, at least, 
some retention of liquor amnii, being niuch 
more desirable. Fetal mobility and some de- 
gree of cervical dilation are, of course, essen- 
tial. The operation may seek to bring either 
the head or breech to the pelvic inlet. 




Fig. 58.— How the hand on the abdomen may assist 
that in the uterus. 

The obstetric position having been taken by 
the patient, the abdominal muscles relaxed, 
the greater part or the whole of one hand is 
passed into the vagina and the fingers enter 
the cervix and touch the presenting part. 



258 MANUAL OF OBSTETRICS. 

The other hand is placed on the abdomen 
over that pole of the child which is to be 
brought to the brim of the pelvis. The fin- 
gers in the cervix seek to move the present- 
ing part away from the pelvic brim toward 
the side opposite to that at which the hand 
externally is applied. The hand on the ab- 
domen seeks to depress the part which it 
covers, and bring it to the superior strait. 
When the other end of the fetus has been 
moved well away laterally, the hand of an 
assistant is useful to raise it toward the fundus 
uteri. Efforts should be made in the inter- 
vals of pains only. Such attention as that 
already spoken of is necessary to maintain 
the corrected position. 

Internal Podalic Version. — This is the 
most common of the operations of turning. 
It is called for when the methods already de- 
scribed have failed; when in shoulder cases 
there is absence of liquor amnii and fixation 
of the child to such degree as to make the 
other operations unlikely to succeed; when, 
arising from other obstetric complications, 
there is reason for prompt and rapid delivery. 
The patient should always receive an anaes- 
thetic, and be placed in the obstetric position, 
the bladder and rectum being empty. Clean- 



MANUAL OF OBSTETRICS. 257 

liness and antiseptic precautions should pre- 
vail. The cervix should be two-thirds dilated. 

In deciding which hand is to be introduced 
into the uterus, a mental picture of the posi- 
tion of the child should be made, and that 
hand should be used which will most readily 
pass, palm forward, toward the feet, the wrist 
flexing to adapt the arm to the pelvic curve. 
In head cases, the hand corresponding to the 
side toward which the child's abdomen is di- 
rected is most suitable. In shoulder cases, 
either dorso-anterior or dorso posterior, if the 
head is to the mother's left, the right hand 
will be used most conveniently; in the other 
positions of the shoulder, let the operator 
employ the left hand. 

If an arm is prolapsed, replace it if this can 
be readily done, or allow it to remain beside 
the operator's arm. Bare the arm to the el- 
bow, thoroughly anoint it with vaseline, and, 
bringing the thumb and fingers into apposi- 
tion, carry the hand into the vagina, through 
the cervix, and past the abdomen of the child 
in the direction of the feet. No efforts 
should be made or continued during uterine 
contractions, and care should be taken that 
fingers or knuckles do not forcibly impinge 
upon the uterine wall. If the feet are to- 



MANUAL OF OBSTETRICS. 



259 



gether, grasp and bring down both, or seize 
the more remote of the two, which will be 
that of the side opposite to the presenting 
shoulder. The child will turn more readily 




than if the foot corresponding to the present- 
ing part be brought down, it being sometimes 
necessary, when the latter has been secured, 



260 MANUAL OF OBSTETRICS. 

to again introduce the hand to secure the 
other foot before the child will revolve on its 
long axis. 

In case it is required to seek the second 
foot, retain the first by attaching a piece of 
broad tape to the ankle. 

In all ordinary cases, if the manipulations 
are being performed in a proper manner, no 
great force is called for. The other hand em- 
ployed externally can often greatly aid in the 
turning by depressing the breech or raising the 
head. When version is accomplished, the case 
resembles that of breech, and, unless there are 
reasons for hasty delivery, should be allowed 
to proceed as has been advised under the con- 
sideration of breech presentation. If imme- 
diate delivery is called for, draw down the 
body, seek the arms in the manner already 
recommended, which are likely to be beside 
the head, and empty the uterus. During de- 
livery, take advantage of, and promote ute- 
rine action. 

Difficulties which may be encountered 
are, first, to distinguish between the foot and 
hand when the former is being sought. 
Avoid mistake by a calm examination of each 
portion of the fetus with which the hand 
comes in contact. Second, the hand of the 



MANUAL OF OBSTETRICS. 261 

operator may become more or less wearied 
and incapacitated by vigorous uterine action. 
To prevent this, relax and rest the hand occa- 
sionally, avoid exciting the uterus by violent 
efforts, and operate only in intervals of con- 
traction. This conduct may also avert injury 
to, and even rupture of the uterus. Third, in 
neglected and impacted shoulder cases, after 
one of the feet is brought down (and in this 
class of cases one only can be obtained usu- 
ally), the child may not revolve, and the part 
originally presenting shows no disposition to 
move from its position at the pelvic inlet. To 
overcome this complication, attach to the foot 
a piece of tape or bandage and, making trac- 
tion by this with one hand external to the 
vulva, seek, with the other in the vagina, to 
push upward and liberate the impacted shoul- 
der. Fourth, the funis may prolapse and 
must be protected according to the means 
best suited to each case. 

Turning in Placenta Previa may be per- 
formed when the cervix is less dilated than to 
that degree which would be required in other 
cases, for the cervix is so dilatable that it 
will readily yield to the pressure of the hand, 
and of the descending body of the child. If 
the placenta is laterally situated, the method 



262 MANUAL OP OBSTETRICS. 

by combined external and internal manip- 
ulation may accomplish the object. If it 
fail, pass the hand through the membranes 
and reach the feet. When the placental im- 
plantation is central over the internal os, pass 
the hand between placenta and uterus in 
the direction of the location in which palpa- 
tion has shown the feet to be situated. After 
passing the hand beyond the margin of the 
placenta, penetrate the membrane. This is 
much better than to attempt to introduce the 
hand through the placenta. 

INDUCTION OF ABORTION AND PREMATURE 
LABOR. 

There are sometimes reasons why, in the 
interest of the mother, and perhaps in behalf 
of the child, it is inadvisable to permit preg- 
nancy to go to term. When interference is 
solely for the sake of the mother, that period 
in pregnancy is selected which offers the 
greatest prospect of a safe result to her. 
When the circumstances calling for interrup- 
tion of pregnancy permit, with safety to the 
mother, that condition to proceed until con- 
siderably advanced, the hope arises that the 
child too may be saved, and the endeavor is 
made in its interest, to pass beyond the time 



MANUAL OF OBSTETRICS. 263 

of viability, the attendant feeling always 
that the mother's safety should never be at all 
involved by this effort. 

The Production of Abortion may be 
called for in chronic organic disease of the 
kidneys, liver, or heart, in irremediable vom- 
iting, incarceration of a displaced uterus, 
cancer of the cervix, and when pelvic deform- 
ity exists with the conjugate reduced to an 
inch, though in this latter class of cases such 
difficulty and danger may attend the opera- 
tion that an obstetric operation at the end of 
pregnancy may be more safe. 

The best time for such operation is when 
gestation is advanced about two and a half 
months, the products of conception then usu- 
ally escaping entire. Other periods are pre- 
ferred by some. 

The safest method is by the introduction of 
laminaria tents, several of increasing size, 
successively introduced, being often neces- 
sary. As soon as uterine contractions are 
excited, ergot may be given. Ergot, qui- 
nine, and oxytocics generally, cannot be de- 
pended upon to excite abortion, though pre- 
paratory to mechanical interference, the 
daily use of the hot, vaginal douche, and slight 
purgation may prove useful, relaxing mea- 



264 MANUAL OF OBSTETRICS. 

sures, even in some cases, meeting a more full 
purpose. The uterine so und or some similar 
instrument may be used to puncture the 
membranes, but this method has its draw- 
backs. It is less prompt in its results, allow- 
lowing time for changes of decomposition, 
the vitality of the fetus and membranes hav- 
ing been destroyed usually by the rupture, 
and the products of conception are quite like- 
ly to be passed in a fragmentary way. 

Induction of Premature Labor may be 
called for in contracted pelvis, in nephritis, 
organic affections of the liver or heart, pla- 
centa previa, accidental haemorrhage, tumors, 
uncontrollable vomiting, pernicious anoz- 
mia, uraimic convulsions, and in women who 
haoitually bear large children: in the interest 
of the child solely, when there has been re- 
peated loss of children late in pregnancy from 
placental disease. In this latter class of 
cases, the time at which to act must be deter- 
mined by' closely watching for indications of 
failing fetal vitality, i. e., weak and irregular 
heart and feeble movements. 

The methods employed are those for excit- 
ing uterine action and those accelerating it. 
Oxytocics, and mammary or rectal irritation 
are unreliable for the first, and the former 
sometimes harmful for the second object. 



MANUAL OF OBSTETRICS. 265 

Catheterization. A new, soft rubber or gum 
elastic bougie or catheter, one somewhat 
stiff being preferable, may be passed be- 
tween the membranes and uterine wall until 
the fundus is approached, and the instrument 
allowed to remain in position for ten or 
twelve hours. Repetition of this procedure 
may be required before uterine action is ex- 
cited, and several attempts of this kind may 
fail to accomplish the desired result. Little 
danger of disturbing the placenta is to be 
feared, for the instrument, if it touches the 
placental border, will pass to one side of that 
organ. Retention of the instrument may be 
effected by a small vaginal tampon. In pri- 
miparse a small laminaria tent may be first 
required to cause dilatation of the cervix 
sufficient for the passage of the bougie. 

Puncture of membranes may be made op- 
posite the cervix, or at a point a short distance 
above, by an instrument arranged for the pur- 
pose. The advantage of the latter method is 
from gradual escape of liquor amnii. It may 
be done by any sharp instrument, wounding 
of the uterus being carefully avoided. 
Prompt uterine action is rarely excited in 
this way, days often elapsing. Labor lacks 
the assistance of the membranous wedge, 



266 MANUAL OF OBSTETRICS. 

and the child may be harmed by the close ap- 
plication of the uterus to it. 

One advantage attending this method is 
decreased risk of infection which may attend 
the retention of an instrument against the 
inner uterine wall. 

Separation of the membranes from the lower 
uterine segment. Dilatation of the cervix 
must be present sufficient to admit the finger 
which is to be repeatedly swept about, and 
the membranes detacfted from the uterine 
wall in all directions to the fullest extent 
possible. It is disagreeable and tedious to 
patient and physician and may act tardily or 
not at all. 

Intra-uterine injections. This measure is 
accomplished by passing a catheter about two 
inches into the uterus between the membranes 
and uterine wall, and injecting an ounce or 
more of warm water. Some have advised to 
continue the injection until the patient com- 
plained of discomfort from uterine tension. 
As much as a quart of water has been inject- 
ed. The procedure is followed by labor which 
shows a degree of promptitude corresponding 
to the amount of liquid employed and the de- 
gree of penetration toward the fundus. If 
the injection is small, repetition may be neces- 



MANUAL OF OBSTETRICS. 267 

sary. Fatal results have attended this vari- 
ety of treatment, due to shock, injection of air 
into the sinuses, and to mechanical injury of 
the uterus, the larger the injection the greater 
being the danger. 

Vaginal douche. For securing immediate 
results this method is fruitless, for a number 
of days, and even weeks, during which it is 
employed twice daily, may elapse before a 
response is obtained. The measure may 
wholly fail. Each douche should, for a period 
of half an hour, project a stream of some 
force against the cervix. Two effects which 
may be noted are, a relaxed and softened 
cervix, and uterine action excited in a reflex 
way. The water should be as warm as the 
patient will tolerate. The method is open to 
the risk of entrance of air, into the cervix and 
uterus, from such admixture with the water 
passing through the syringe. 

The Barnes dilators, when cervical dilata- 
tion is present sufficient to allow the intro- 
duction of the smallest size, can be used to 
mechanically dilate the cervix, provoking, as 
they often do, uterine action as well. They 
are of special value to expedite labor which, 
when induced prematurely, is often charac- 
terized by inefficient contractions. If the 



263 MANUAL OP OBSTETRICS. 

head presents, there is liability to its displace- 
ment by the distended rubber bag and the 
shoulder may succeed it as the presenting 
part. 

Premature labor, when induced, is apt to 
be tardy, with inefficient pains. Rupture of 
the membranes will accelerate it, and is 
proper when the cervix will admit four fin- 
gers. Other measures, such as have been 
recommended in tedious labor and for rigid 
os, should be employed. 

LAPARO-ELYTROTOMY (THE THOMAS OPE- 
RATION). 

When pelvic deformity exists to a high de- 
gree, it may be advisable to extract the child 
in a way that will avoid its passage through 
the pelvis. This is called for not alone in the 
interest of the child, for statistics of craniot- 
omy and embryotomy, when performed 
through pelves greatly contracted, show a 
high rate of mortality for the mother. The 
operation of laparo-elytrotomy meets these 
indications, and differs from Cesarean section 
inasmuch as the peritoneum and uterus are 
not wounded. 

In the consideration of the operation in a 
given case, the size of the child is to be con- 



MANUAL OP OBSTETRICS. 269 

sidered as well as the degree of deformity. 
Preliminary to the operation the cervix must 
have been dilated spontaneously or by the aid 
of the Barnes bags, bladder and rectum being 
empty. 

An incision is made on the right side, par- 
allel to, and an inch above Poupart's liga- 
ment, beginning above the anterior, superior 
spine of the ilium, and extending to within 
an inch and three-quarters of the spine of 
the pubis. The inner extremity of the incis- 
ion should be about an inch and a half above 
the pubes. The abdominal muscles are then 
divided throughout the line of the incision. 
The peritoneum, when reached, is to be care- 
fully lifted up from the iliac and transversalis 
fasciae until the fingers reach the vaginal wall. 
The uterus is lifted forcibly upward, and to 
the left. A metal catheter kept in the blad- 
der indicates the situation of that organ, 
which must not be injured. A blunt, wooden 
instrument, as large as a medium-sized rectal 
bougie, should be passed into the vagina and 
pressed upward; to bring the vagina as near 
to the abdominal wound as possible. A 
small cut is then made in the vagina. This 
must be as low down as possible — about an 
inch and a half below the cervix. By this 



270 MANUAL OF OBSTETRICS. 

low incision the ureter, which is situated at 
a higher level, and the pouch of Douglas are 
avoided, and there are fewer vessels encoun- 
tered liable to be injured. 

The vaginal wound should then be enlarged 
by tearing with the fingers forward toward 
the pubes and backward in the direction of 
the sacrum. The fundus of the uterus being 
then brought well to the opposite side, the 
operator proceeds to withdraw the child 
through, successively, the os uteri, the vagi- 
nal wound, and the abdominal incision. 
Removal of the child may be accomplished 
by the forceps or version, the placenta follow- 
ing by the same channel. Haemorrhage 
should be met by pressure, or styptic appli- 
cations. 

Vesico-vaginal fistula, if occurring, should 
be closed by silk or catgut sutures. A drain- 
age tube should be passed through from the 
abdominal wound into the vagina, and the 
greater part of the abdominal wound closed 
by stitches and adhesive plaster. 

During healing, the wound 'must be kept 
clean by antiseptic injections. 

CESAREAN SECTION. 

The removal of the child by abdominal and 



MANUAL OF OBSTETRICS. 271 

uterine section, the peritoneal cavity being 
opened, is called for in high grades of pelvic 
deformity, when, as far as can be judged, the 
dangers to the mother would be less by such 
delivery than would attend operative extrac- 
tion by the natural passages. Advanced can- 
cer of the cervix and solid tumors, occupying 
persistently the pelvic cavity, may require 
such treatment. For the purpose of saving 
the child, the operation may be performed as 
the speediest and safest way of delivery after 
death of a pregnant woman. 

The greatest success will follow this opera- 
tion when there has been the most full observ- 
ance of details with reference to the supply of 
suitable instruments, the presence of uncon- 
taminated atmosphere, extreme precautions of 
cleanliness and disinfection, and selection of 
a time before exhaustion of the patient. If 
possible, operate before rupture of the mem- 
branes, ether being the anaesthetic to be em- 
ployed. The abdominal muscles should be 
relaxed by moderate flexion of the knees as 
the patient lies on her back. The bladder 
should be emptied by a medical attendant. 

Operation. — An incision through the abdo- 
minal wall is made in the linea alba, there 
being few vessels liable to be cut in that situ- 



272 MANUAL OF OBSTETRICS. 

ation, and layer by layer the tissues are 
divided, the incision being carefully kept in 
the line of the original cut, until the perito- 
neum is reached. The incision should extend 
from the navel to within an inch and three- 
quarters of the pubes. All bleeding should 
have ceased before the peritoneum is opened. 
This membrane should be penetrated and the 
opening extended by cutting from within 
outward, the intestine being carefully kept 
away from the reach of the knife. 

The care of the intestines and the manage- 
ment of the uterus should be given to one 
assistant, who should now compress the latter 
organ laterally, and bring the middle of it 
opposite to, and well forward against the ab- 
dominal wound. The incision in the uterus 
should be four or five inches in length, but 
should not involve either the fundus or the 
cervix. The incision should be made as 
quickly as is consistent with safety, and when 
the uterine cavity is opened, the assistant 
should introduce a finger at each extremity 
of the wound, and hook the organ up against 
the abdominal wall. This procedure prevents 
the entrance of blood and liquor amnii into 
the peritoneal cavity, as well as escape of 



MANUAL OF OBSTETRICS. 273 

loops of intestine through the abdominal 
wound. 

The child should be quickly removed — if 
convenient the head being first seized, for 
when taken out feet first, the incision may 
contract around the neck and inconvenience 
the operator in subsequent delivery of the 
head, or lead to a ragged tear of the uterus. 
The placenta and membranes are next care- 
fully extracted. If the former has been 
wounded when the uterine incision was 
made, its speedy removal is necessary to 
check dangerous haemorrhage. As the uterus 
decreases in size, owing to escape of its con- 
tents, the assistant carefully guards against 
protrusion of the intestines. When severe 
haemorrhage occurs, if some extrusion of the 
uterus can be produced, the loss of blood can 
be kept external to the abdominal cavity. 
Complete contraction of the uterus, after 
delivery of the fetus and secundines, is essen- 
tial, and, if necessary, direct manual compres- 
sion may be employed, all clots being removed 
from its cavity by the fingers. 

Interrupted carbolized silk sutures should 
close the incision in the uterus, and, to ap- 
proximate the peritoneal edges, a few super- 
ficial stitches may be added. 



274 MANUAL OF OBSTETRICS. 

The peritonei cavity, especially the de- 
pendent region of the recto-uterine pouch, 
should be cleansed perfectly of all material 
foreign to its surface. The abdominal wound 
should be closed with wire or silk sutures, or 
hare-lip pins, and in every case care should 
be taken that the peritoneal edges are neatly 
brought together. The abdomen having been 
cleansed, it should be covered with an anti- 
septic dressing. 

Subsequent treatment consists in placing 
the patient under a competent nurse who will 
carry out, in every detail, directions which 
should enjoin absolute quiet and simple diet. 
The catheter should be employed and puer- 
peral disorders met with appropriate treat- 
ment. 

Dangers are those of haemorrhage, metritis, 
and peritonitis, exhaustion from an operation 
which is often performed when the patient is 
already prostrated by a long and difficult la- 
bor, shock, and septicaemia. 

THE PORRO OPERATION. 

This is a modification of the Caesarean ope- 
ration, consisting in the final ablation of the 
greater part of the uterus and the ovaries. It 
is intended to remove the risk from leakage 



MANUAL OF OBSTETRICS. 275 

of blood through the uterine wound into the 
abdominal cavity, which is liable to occur 
after the Csesarean section. The operation 
does not differ from the one previously de- 
scribed until after the emptying of the uterus. 
Then the organ is raised through the abdomi- 
nal wound, and a strong wire, by means of 
the ecraseur, or a clamp is placed about the 
neck, above the internal os, which is con- 
stricted until the circulation is arrested per- 
manently. The uterus is then amputated, 
and the stump, after being seared with the 
Pacquelin cautery, is fastened in the abdomi- 
nal wound as is sometimes done with the 
pedicle after ovariotomy. The clamp or wire 
must not lacerate the peritoneum. The stump 
separates at the end of two weeks. 

The Porro-Muller Operation leaves the 
same result finally, and differs from the Porro 
operation in that the uterus is lifted through 
the abdominal incision before it is opened. 
The delivery of the uterine contents is accom- 
plished, therefore, with the uterus external 
to the peritoneal cavity, and the passage of 
blood and liquor amnii into the latter cavity 
during the operation can be effectually pre- 
vented. This procedure requires an incision 
of at least six or seven inches, and a long in- 



276 MANUAL OP OBSTETRICS. 

cision always adds to the danger in abdomi- 
nal surgery. The cervix is to be constricted 
before the uterus is opened, and the child to 
be then extracted with speed. 

Laparotomy for rupture of the uterus. — 
After what has been said regarding Caesarean 
section, little need be written on this subject. 
The general principles governing one opera- 
tion would apply to the other. The uterine 
rent should be closed by sutures and especial 
attention be given to replacement and coapta- 
tion of the peritoneum investing the uterus. 
It is common to find that this layer has been 
lifted up from the uterus to some extent be- 
fore yielding an aperture for the escape of 
the child into the abdomen, and therefore the 
rent in the peritoneum may not correspond 
to the tear in the uterine muscle. 

The cleansing of the abdominal cavity 
should be thorough. 

In some cases, when the lacerated and 
irregular character of the uterine rent would 
indicate that, after the most careful closure 
by stitches, primary union would fail to oc- 
cur, and some escape of blood into the perito- 
neal cavity would continue after the opera- 
tion; in cases in which, owing to the softened 
and degenerated condition of the uterine wall, 



MANUAL OF OBSTETRICS. 277 

the ordinary tension of sutures would cause 
them to tear the tissues; or when pelvic de- 
formity is present to a degree to make it 
undesirable that a woman should again be- 
come pregnant, it would be quite proper to 
raise the question of the advantage which 
might be gained from ablation of the greater 
part of the uterus, as is done in the Porro 
operation. 



INDEX 



Abdominal gestation, 66 
Ablation of the uterus after its rupture, 277 
Abortion, spontaneous, 58 
induction of, 262 
Accidental haemorrhage, 160-167 
Adhesion of placenta, 175 
Afterpains, 101 

Air, entrance of, into uterine vessels, 201 
Albuminuria, 55, 194 
Allantois, 29 
Amnion, 27 
Anatomy of the pelvis, 69-77 

of the fetal head, 77-79 
Anchylosis of sacro-iliac synchondrosis, 119, 121 
Ante-partum haemorrhage, 160 

hour-glass contraction of the uterus, 113 
Arbor vitae, 11 
Area germinativa, 27 

pellucida, 27 
Arm, dorsal displacement of, 157 

presentation, 142-146 
Arms, how to bring them down, 132, 260 
Articulations, pelvic, 73 

rupture of, 191 



280 INDEX. 

Atresia of vagina and cervix, 114 
Axes of pelvis, 77 

Bacteria in puerperal fever, 211 

Ballottement, 47 

Barnes' dilators in accidental haemorrhage, 166 

dilators in induction of premature labor, 267 

dilators in placenta previa, 171 

dilators in puerperal eclampsia, 195 

dilators in rigidity of the cervix, 112 

dilators in tedious labor from uterine inertia, 
110 
Bartholin, glands of, 5 
Binder after labor, 100 
Bladder, care of, after labor, 101 

containing calculus, obstructing labor, 115 
Blastodermic membranes, 27 
Blood, changes in, during pregnancy, 40 
Blunt hook, 244 

Breast signs in pregnancy, 42-44 
Breasts, management of, 104 
Breech presentation, 126 

presentation, causes of, 128 

presentation, diagnosis of, 128 

presentation, impacted, 1 33 

presentation, mechanism of, t30 

presentation, prognosis in, 130 

presentation, treatment of, 131 
Bregma, 78 
Brow presentation, 140 

presentation, treatment of, 141 
Bruit, uterine, in pregnancy, 48 
Bulbi vestibuli, 4 

Caesarean section, 113, 125, 270 



INDEX. 281 

Calculus, vesical, obstructing labor, 115 
Cancer of cervix obstructing labor, 113 
Caput succedaneum, 92 
Carneous mole, 61 
Carunculae myrtiformes, 7 
Cephalic version, 251 
Cephalotribe, 244, 247 
Cephalotripsy, 240, 247, 248 
Cervix, cancer of, 113 

changes in, during pregnancy, 45 
lacerations of, 190 
rigidity of, 111 
Cessation of menses, 41 
Chloral in eclampsia, 196 
in insanity, 205 
in insomnia, 53 
in rigidity of the cervix, 112 
Chorea, 53 
Chorion, 31 
Circulation of the fetus, 37 

omphalo-mesenteric, 29 
Clitoris, 2 
Coccyx, 70 
Colostrum, 104 

Combined external and internal version, 254 
Commissures of the vagina, 2 
Conception, 23 
Convulsions, uraemic, 192 
Cord, formation of, 36 

prolapse of, 180-184 
treatment of, after birth of head, 98 
treatment of, in breech presentation, 132 
tying of, 98 
Corpora cavernosa, 2 



282 INDEX. 

Corpus luteum, 21 
Cranioclast, 243 
Craniotomy, 240 

forceps, 242 

operation of, 244 
Cranium, premature ossification of, 154 
Crotchet, 244 
Cystocele obstructing labor, 115 

Death, delivery of child after, 271 
sudden, after labor, 198, 201 

Decapitating hook, 250 

Decapitation, 249 

Deciduse, 33 

Deformity of the pelvis, 117 

of the pelvis, dangers from, 121 

of the pelvis, diagnosis of, 122 

of the pelvis, treatment of labor in, 125 

Delivery, care after, 100-105 

premature, 58, 264-268 

Descent of head in labor, 87 

Diagonal conjugate, 124 

Diameters of fetal head, 78 
of pelvis, 76 

Diarrhoea of pregnancy, 52 

Dilatation of cervix, how effected, 81 

Diseases of pregnancy, 50-57 

Discus proligerus, 20 

Dorsal plates, 27 

displacement of arm, 157 

Double uterus, 68 

Douche, in protracted first stage of .labor, 110, 112 
in puerperal fever, 223 
to induce labor, 266, 267 



\ 



INDEX. 283 



Douglas, cul-de-sac of, 6 
Ductus arteriosus, 38 

venosus, 37 
Dry labor, 158 

Eclampsia, 192-196 

Electricity in extra-uterine pregnancy, 67 

in post-partum haemorrhage, 177 

Elytrotomy in extra-uterine pregnancy, 66 

Embolism, 196-201 

Embryotomy, 248 

Endocolpitis, 214 

Endometritis, 214 

Epiblast, 27 

Erectile tissue, 4 

Ergot of rye, 99 

Eustachian valve, 37 

Excessive fetal development, 154 

Exostoses, 117 

Expression of placenta, 99 

Expulsion, spontaneous, 146 

Extension of head in labor, 88 

External rotation, 89 
version, 252 

Extra-uterine pregnancy, 63 

pregnancy, varieties of, 64 
pregnancy, signs of, 65 
pregnancy, treatment of, 67 

Evisceration, 249 

Face presentation, diagnosis of, 138 
presentation, mechanism in, 135 
presentation, prognosis in, 138 
presentation, treatment of, 139 
presentation, varieties of, 134 



284 INDEX. 

Fallopian tube, 13 
False pains, 93 
Fatty mole, 62 

Feces, impacted, obstructing labor, 115 
Fecundation, 24 
Fetal circulation, 37 
head, 77 
heart, 48 
Fever, puerperal, 207-225 
Fibroid tumors obstructing labor, 114 
Flexion of head in labor, 86 
Footling presentation, 126 
Foramen ovale, 37 
Forceps, 226-239 

in face presentation, 239 
in occipito-posterior cases, 239 
of Tarnier, 228 

preliminaries to the use of, 230 
the operation, 231 
to the after-coming head, 237 
varieties of, 227-228 
Fornix vaginae, 7 
Fossa navicularis, 6 
Fourchette, 2 
Funis, structure of, 36 
long, 159 

prolapse of, 180-184 
short, 159 

treatment of, after birth of head, 98 
treatment of, in breech presentations, 132 
tying of, 98 

Gastrotomy, vide laparotomy, Ceesarean section 
Gelatin of Wharton, 37 



INDEX. 283 

Generative organs, external, 1 
organs, internal, 7 
Germinative vesicle and spot, 21 
Glands of Naboth, 11 

utricular, 10 

vulvo-vaginal, 5 
Glans clitoridis, 2 
Globule, polar, 25 
Graafian follicle, 18 

HsBmatocele, 116 
Hemorrhage, accidental, 160-167 
post-partum, 173-179 
secondary post-partum, 179 
unavoidable, 167-173 
Hand presentation, 144 
Head, anatomy of the fetal, 77 

dolicho-cephalic, 134 

premature ossification of, 154 

presentation, mechanism of, 84 
Heart sounds, fetal, 48 

High grades of pelvic deformity, treatment in, 268-271 
Hook, the blunt, 244 

Hour-glass contraction of uterus, ante-partum, 113 
contraction of uterus, post-partum, 171 
Hydatidif orm mole, 62 
Hydrate of chloral, 112, 196, 205 
Hydrocephalus, fetal, 155 
Hydrothorax, 156- 
Hydroperitoneum, 156 
Hymen, 7 
Hypoblast, 2? 

Impregnation, site of, 24 



286 INDEX. 

Inclined planes of the pelvis, 74, 75 

Inertia uteri, 110, 173 

Induced abortion, 262 

Induction of premature labor, 264 

Injections in post-partum haemorrhage, 177 

to induce labor, 266, 267 
Innominate bone, 71 
Insanity, puerperal, 202 
Insomnia in pregnancy, 53 
Instruments for perforation, 240 
Intermittent uterine contractions, 47 
Internal organs of generation, 7 

version, 256 
Interstitial pregnancy, 64 
Inversion of the uterus, 184-186 
Involution of the uterus, 103 

Jaundice in puerperal fever, 222 

Kiestine, 44 

Knee presentation, 126 

Labia majora, 1 
minora, 3 
Labor, causes of, 79 

difficult, from obstructions in soft parts, 111-117 

duration of, 84 

management of, 92 

mechanism of, 84 

phenomena of, 80-83 

powerless, 110 

precipitate, 107 

premature, 58, 59, 264-268 

stages of, 80 

tedious, 108 



INDEX. 287 

Lacerations of the cervix, 190 

of the maternal structures, 178 
of the perineum, 191 
of the vagina, 190 
Lactation, 104 

insanity of, 203, 205 
Laminae dorsales, 27 
Laparo-elytrotomy, 268 

hysterotomy, vide Ceesarean section 
Laparotomy for rupture of the uterus, 276 
in extra-uterine pregnancy, 67 
Ligament, broad, 10, 12 

of the ovary, 14 
round, 13 
sacro-iliac, 73 
sacro-sciatic, 74 
sacro-uterine, 12 
vesico-uterine, 12 
Liquor amnii, 31 
Lochia, 102 
Locked twins, 150 
Long funis, 159 

Malacosteon, 117 

Malpresentations, 126-147 

Mammary glands, management of, 104 

signs of pregnancy, 42 
Management of labor, 92 
Mania, 204 
Masculine pelvis, 120 
Meatus urinarius, 4 
Mechanism of normal labor, 84 
Melancholia, 202 
Membrana granulosa, 20 



288 INDEX. 

Menstruation, 22 

cessation of, in pregnancy, 41 
Mesoblast, 27 
Metritis, 215 
Micrococci, 212 
Molar pregnancy, 61-63 
Monsters, 156 
Mons veneris, 1 

Morning sickness of pregnancy, 42 
Movements, fetal, 46, 47, 48 
Multiple pregnancy, 47 
Muriform body, 27 

Naboth, glands of, 1 1 

Natural labor, 79 

Nervous disturbances of pregnancy, 53 

Nipples, care of, after labor, 105 

care of, during pregnancy, 93 
changes in, during pregnancy, 43 

Nymphse, 3 

Oblique diameters of the pelvis, 76 
Obstetric operations, 226-277 
Obstructions in maternal soft parts, 111 
Occipito-posterior cases, 141 
Omphalo-mesenteric circulation, 29 
Organs of generation, external, 1 
of generation, internal, 7 
Ossification, premature, of fetal head, 154 
Osteo-malacia, 119 
Osteophytes, 41 
Os uteri, changes in, during labor, 80-82 

uteri, changes in, during pregnancy, 45 

uteri, oedema of, in labor, 112 

uteri, rigidity of, in labor, 111 



INDEX. 289 



Ovarian pregnancy, 63 

tumors obstructing labor, 114 
Ovary, anatomy of, 14 
Ovulation, 21 
Ovule, 20 
Ovum, changes in, 25 

Pains, false, 93 

Parametritis, 216 

Parovarium, 15 

Pars intermedia, 4 

Pelvic joints, rupture of, 191 

Pelvimetry, 123 

Pelvis, anatomy of, 69 

as a whole, 74 

deformed, varieties of, 117-121 

diameters of, 76 

figure of eight, 118 

infantile, 120 

ligaments of, 73 

male, 120 

measurements of, 76 

oblique, 119 
Perforation of the after-coming head, 246 

of the fetal cranium, 244 
Perforators, 241 
Perimetritis, 218 
Perineum, structure of, 6 

laceration of, 191 
management of, 96 
rigidity of, 115 
Peripheral arterial embolism, 201 

venous thrombosis, 198 
Peritonitis, 219 



290 INDEX. 

Phlegmasia dolens, 198 
Pigmentation, 44 
Placenta, adhesion of, 175 
anatomy of, 34 
delivery of, 83, 99 
previa, 167-173 
previa, version in, 261 
Plexus pampiniformis, 16 

uterinus, 16 
Plural births, 147 
Podalic version, 256 
Polar globule, 25 
Porro-Muller operation, 275 
Porro operation, 274 
Post-mortem laparotomy, 271 
Post-partum haemorrhage, 173-179 
Powerless labor, 110 
Precipitate labor, 107 
Pregnancy, changes in cervix during, 44 
changes in uterus during, 44 
condition of blood in, 40 
diseases of, 50 
duration of, 49 
extra-uterine, 63 
mammary changes in, 42 
morning sickness of, 42 
multiple, 147 
signs of, 40 
Premature labor, occurrence of, 58 
labor, induction of, 264 
ossification of fetal head, 154 
Presentation, 84 

multiple, 157 
Primitive trace, 27 



INDEX. 291 

Prolapse of the funis, 180-184 

Pruritus vulvae, 53 

Pubic arch, 76 

Pudendum, 1 

Puerperal convalescence, management of, 101 

eclampsia, 192-196 

embolism, 196-201 

fever, 207-225 

fever, prevention of, 222 

fever, treatment of, 222 

insanity, 202 

peritonits, 219 

phlebitis, 198-201 

septicaemia, 220 

state, 100 

thrombosis, 196-201 
Pyaemia, 200 

Quickening, 46 

Rachitis, 117 

Respiratory chamber, 25 

Restitution in mechanism of labor, 89 

Retroversion of the uterus in pregnancy, 56 

Rigidity of the cervix, 111 

of the perineum, 115 
Rima pudendi, 2 
Robert's pelvis, 121 
Rosenmuller, organ of, 15 
Rotation of head in labor, 88, 90 
Rupture of the pelvic joints, 191 

of the perineum, 191 

of the uterus, 186-190 

of the vagina, 190 



292 INDEX. 

Sacro-iliac ligament, 73 

iliac synchondrosis, 73 
sciatic ligaments, 74 

Secondary post-partum haemorrhage, 179 

Segmentation of the vitellus, 26 

Semen, 23 

Septicaemia, 200, 220 

Short funis, 159 

Shoulder presentation, varieties of, 142 
presentation, diagnosis of, 143 
presentation, treatment of, 147 
presentation, version in, 251, 257 

14 Show," the, 80 

Sore nipples, 105 

Spermatozoon, 23 

Sphincter vaginae muscle, 7 

Spondylolisthesis, 120 

Spontaneous expulsion, 146 
version, 145 

Straits of the pelvis, 75 

Stages of labor, 80 

Styptics in post-partum haemorrhage, 177 

Superfecundation, 153 

Superfetation, 152 

Suppression of menses in pregnancy, 41 

Sutures of fetal cranium, 77 

Symptoms and signs of pregnancy, 40 

Syncope in pregnancy, 54 

Tampon in abortion, 61 

in placenta previa, 171 
Tarnier, forceps of, 228 
Tedious labor, 108 
Thomas 1 operation, 268 



INDEX. 298 

Thrombosis, puerperal, 196-201 

Tough membranes, 158 

Transfusion of blood, 178 

Transverse presentation, causes of, 142 

presentation, diagnosis of, 143 
presentation, natural termination of, 144 
presentation, prognosis in, 143 
presentation, treatment of, 147 
presentation, varieties of, 142 

Triplets, 147 

Twin pregnancy, 147 

pregnancy, diagnosis of, 149 
labor, peculiarities of, 149 
labor, prognosis of, 150 
labor, treatment of, 151 

Twins, locking, 150 

Tubal pregnancy, 64 

Tubes, Fallopian, 13 

Tumors obstructing labor, 114 

Tunica albuginea, 15 

Turning, vide version, 251 

Umbilical cord, see funis 

vesicle, 28 
Unavoidable haemorrhage, 167-173 
Ursemia, 193-196 
Urethra, 4 

Urine, albumen in, 55, 194 
kiestine in, 44 

retention of, in pregnancy, 54 
Uterine bruit, 48 
Uterus, anatomy of, 7 

contractions of, during pregnancy, 47 
double, 68 



294 INDEX. 

Uterus, inertia of the, 110, 173 

inversion of the, 184-186 

involution of the, 103 

lymphatics of the, 16 

nerves of the, 16 

removal of the, after laparotomy in uterine 
rupture, 276 

rupture of the, 186-190 

utricular glands of the, 10 

vessels of the, 10 
Utricular glands, 10 

Vagina, anatomy of, 6 

atresia of, obstructing labor, 114 
lacerations of, 190 
Vaginal douche for inducing labor, 267 
Varicose veins in pregnancy, 54, 116 
Veratrum viride in eclampsia, 196 
Version, 251 

by combined external and internal manipula- 
tion, 254 

by external manipulation, 252 

by internal method, 256 

cephalic, 251 

difficulties encountered in, 260 

indications for, 251 

in placenta previa, 261 

spontaneous, 145 
Vertex presentations, 84 
Vesicle of evolution, 23 
Vesicular mole, 62 
Vestibule, 4 
Villi of chorion, 32 
Vitellus, 20 



INDEX. 295 



Vitellus, segmentation of the, 26 
Vitelline nucleus, 25 
Vitriform body, 31 
Vomiting in pregnancy, 42 
Vulva, 1 
Vulvo-vaginal gland, 5 

Wharton's gelatin, 36 
Wolffian body, 16 

Yolk of ovum, 20 

Zona pellucida, 20 



